5 Feb 2026 His Honour Bruce Caulfield · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Delays between family concerns and medical review View source Failure of intentional rounding and nursing practices to ensure adequate hydration and nutrition for vulnerable ward patients View source Failure to ensure prominent documentation of agreed sitting-out recommendations across the Trust View source Failure to ensure communication of agreed sitting-out recommendations between physiotherapy and nursing professionals across the Trust View source See 1 more concern
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His Honour Bruce Caulfield · 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
His Honour Bruce Caulfield died at Trafford General Hospital on 19 August 2025 from complications arising from coronary artery disease, against a background including an acute on chronic subdural haematoma requiring surgery, hypertension and frailty. Concerns included the delay between a family member requesting medical review and the review taking place, whether nursing practices ensured vulnerable patients received adequate hydration and nutrition, and whether measures relating to communication about sitting-out recommendations were in place across the Trust.
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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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays between family concerns and medical review
Wider context from the report “1. In relation to events leading up to His Honour’s death at Trafford General Hospital on 19th August 2025, I am concerned as to how long transpired between a family member expressing concerns about a significant change in his condition and requesting a review by a doctor, and any medical review actually taking place ;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of intentional rounding and nursing practices to ensure adequate hydration and nutrition for vulnerable ward patients
Wider context from the report “2. Having considered all of the evidence before the inquest with the utmost care, I am concerned that the approach to intentional rounding at Wythenshawe hospital in conjunction with other relevant nursing practices is insufficient to ensure vulnerable patients (such as those with cognitive impairment or the inability to eat or drink without assistance) receive adequate hydration and nutrition whilst on the wards ;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prominent documentation of agreed sitting-out recommendations across the Trust
Wider context from the report “3. Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these , I am concerned that comparable measures may not be in place across the Trust as a whole .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure communication of agreed sitting-out recommendations between physiotherapy and nursing professionals across the Trust
Wider context from the report “3. Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these, I am concerned that comparable measures may not be in place across the Trust as a whole .
” 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 Formalise Ward Manager and Matron walkarounds to increase assurance of mealtime preparedness and real-time patient feedback.
Verbatim wording from the response “• Ward Manager and Matron walk arounds are in place and are now being formalised as part of increased assurance mechanisms to focus on mealtime preparedness and patient feedback in real time.” Source location Response from Manchester University 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 Increase the volume and frequency of peer dining audits from March 2026, reporting results through senior nursing and nutrition governance.
Verbatim wording from the response “• Increased volume and frequency of peer audits from March 2026 reporting into the weekly Senior Nurse Huddle chaired by ████████ and oversight into the WTWA Nutrition and Hydration Group.” Source location Response from Manchester University 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 Continue enhanced auditing of appropriate food-chart commencement for three months to assure consistent nutrition monitoring across WTWA hospitals.
Verbatim wording from the response “Following His Honour’s admission to Doyle Ward on 23 July 2025, he was placed on food charts on 24 July 2025. This measure allowed staff to track his nutrition status closely and respond promptly to any emerging concerns. An audit of 49 patient records at Wythenshawe Hospital, completed in February 2026, found that 89% of relevant patients had food charts commenced appropriately. This enhanced audit will continue for the next three months to provide further assurance of consistent practice across WTWA hospitals. As part of His Honour’s nutrition and hydration management, he was placed on the ‘red tray system’ on 24 July 2025. The red tray is a visible prompt for staff, indicating that the patient is at high risk of malnutrition and requires assistance with eating or drinking. During his admission, His Honour required encouragement and support with both eating and drinking.” Source location Response from Manchester University 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 Extend the Wythenshawe audit of physiotherapy assessments and nursing review processes across the Trust and report findings through hospital quality and safety groups.
Verbatim wording from the response “For patients sitting out for the first time, or where fatigue risk is identified, AHP staff undertake structured assessments including medical history, baseline function, muscle strength, sitting balance and cognition. Recommendations regarding transfer method and seating are documented in HIVE and verbally handed over to nursing colleagues. Nursing staff implement these recommendations in conjunction with moving and handling risk assessments and ongoing observation.” Source location Response from Manchester University 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 Provide additional nutrition and hydration monitoring through quality and safety walk rounds led by nursing directors, with real-time feedback.
Verbatim wording from the response “• Additional monitoring is being provided through quality and safety walk rounds led by the Director or Deputy Director of Nursing with feedback provided in real time.” Source location Response from Manchester University 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 Roll out Martha’s Rule through an Oak Ward pilot enabling patients and families to request urgent clinical review and a second opinion.
Verbatim wording from the response “The Trust is rolling out Martha’s Rule, a national NHS patient safety initiative that empowers patients and families to request an urgent review and second opinion should they have concerns regarding the clinical condition of the patient. Oak Ward at Trafford Hospital has been identified as a pilot ward within the adult services roll-out. The pilot will commence in April 2026 and will be overseen by a Trust led oversight group and hospital site Quality and Patient Safety Groups.” Source location Response from Manchester University 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 Maintain consistent Trust-wide use of seating charts and documentation of allied health professional recommendations in HIVE for communication and care planning.
Verbatim wording from the response “I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.” Source location Response from Manchester University NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers its comprehensive care approach, including nutrition and hydration support for vulnerable patients, sufficient to address the concern.
Verbatim wording from the response “As you may be aware, ‘intentional rounding’ is a term used to describe a practice in care delivery to patients during their hospital admission; it is a structured proactive nursing process where staff check on patients at regular intervals to address any key needs such as pain, communication and placement of items such as a call bell. Although the terminology ‘intentional rounding’ was used with regards to care provided on Doyle Ward, it is not a term that is widely used across WTWA Hospitals to describe what is a more comprehensive approach to care delivery, which includes assessment and implementation of care. This approach is provided to all patients, including those patients who require support with nutrition and hydration, and those patients with a cognitive impairment.” Source location Response from Manchester University NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that communication and documentation measures for sitting-out recommendations were isolated to Doyle Ward, stating they apply consistently across all inpatient areas.
Verbatim wording from the response “I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.” Source location Response from Manchester University NHS Foundation Trust
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24 Sep 2025 Honoria Culshaw · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Failure to communicate pacemaker extraction referral requirements between specialist and local cardiology services View source
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Honoria Culshaw · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Honoria Culshaw died at home on 25 October 2024 after developing fatal pneumonia following treatment for sepsis from an infected pacemaker site. Her underlying cardiac and immunological conditions contributed to her deterioration after pacemaker extraction surgery. The report identified concern that inadequate communication about the need for pacemaker extraction delayed referral between treating hospitals and specialist services.
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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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate pacemaker extraction referral requirements between specialist and local cardiology services
Wider context from the report “Mrs. Culshaw attended Wythenshawe Hospital on the 10th July 2024 an presented with an opening of her pacemaker scar. I heard evidence at the inquest from ████████, a Consultant Cardiologist at Wythenshawe that International clinical guidance indicates that any opening of an implantation scar should be interpreted as a sign of systemic infection of the wound and that extraction and replacement of the pacemaker should follow in order to remove the infection. This was the advice of the on-call Cardiologist at Wythenshawe on the 10th July 2024 to the Emergency Department medical team. I heard evidence that Wythenshawe is one a limited number of specialist surgical centres for the extraction of pacemakers.
Mrs. Culshaw was not admitted to Wythenshawe Hospital, but discharged to the care of Royal Preston Hospital, where her pacemaker had been fitted. Royal Preston Hospital is not a specialist surgical centre for pacemaker extraction. The expectation of Wythenshawe Hospital at the time of her discharge appears to be that Royal Preston would refer her back to Wythenshawe for extraction. However, the need for extraction and therefore a referral was not communicated by Wythenshawe to either Royal Preston or to Mrs. Culshaw’s GP . It is not clear that it was adequately explained to Mrs. Culshaw’s family.
Mrs. Culshaw re-presented at Wythenshawe on the 9th September, again with signs of infection and underwent an extraction procedure as an inpatient on the 16th September 2024.
However, I found that her experienced persistent and prolonged infection depleting her physiological reserve and contributed to her succumbing to a fatal pneumonia on the 25th October 2024.
I am concerned that this lack of information sharing along a communication pathway between the Cardiology department and specialist surgical extraction team at Wythenshawe and the Cardiology departments at local treating hospitals risks such referrals being delayed or not being made at all , as happened in the present case.
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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 Reinforce with Cardiology the importance of communicating with other secondary and tertiary care providers to maximise continuity of care.
Verbatim wording from the response “We have reinforced with the Cardiology Department that communication with other secondary and tertiary care providers is of paramount importance to ensure continuity of care is maximised for patients. From 15 December 2025 onwards when the tip sheets and video guides are available, Cardiology Residents’ training will include focused education regarding the processes available to copy inpatient discharge letters that are sent to general practitioners to other relevant healthcare providers. This uses the same process within the electronic patient record as medical staff use to send letters following outpatient clinic appointments. This training will be” Source location Response from Manchester University 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 Develop HIVE tip sheets and video guides on using the Emergency Department discharge navigator’s correspondence function and share them with relevant staff.
Verbatim wording from the response “The Trust will also develop additional HIVE tip sheets and video guides to increase knowledge and awareness of the ‘correspondence’ tab in the Emergency Department’s discharge navigator within HIVE. The tip sheets and video guides will be available by 15 December 2025 and shared with all relevant staff members by this date by the Emergency Department’s Clinical Head of Division.” Source location Response from Manchester University 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 Build the HIVE discharge navigator so the correspondence workflow appears in the Emergency Department’s Dispo section.
Verbatim wording from the response “The intention is that the ‘correspondence’ workflow will appear in the ‘Dispo’ section (the discharge navigator for the Emergency Department). This will require a fundamental HIVE build and therefore will not be completed until June 2026.” Source location Response from Manchester University 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 Develop structured Emergency Department discharge communications and built-in referral reminders, while reviewing amendments to the current Emergency Department notes.
Verbatim wording from the response “Onward communication and referral to external providers have been a key area of focus and improvement for the Trust. Following this case, further work is being done with discharge communications from Emergency Departments to provide structured discharge information and also built in reminders to staff that if a referral is required, the correct process is following at the point of discharge. This includes working with digital colleagues to review the practicalities of amending the current Emergency Department notes that are generated by the Trust.” Source location Response from Manchester University 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 Provide Cardiology Residents with focused training on copying inpatient discharge letters to relevant healthcare providers and referring patients to available pacemaker extraction services.
Verbatim wording from the response “We have reinforced with the Cardiology Department that communication with other secondary and tertiary care providers is of paramount importance to ensure continuity of care is maximised for patients. From 15 December 2025 onwards when the tip sheets and video guides are available, Cardiology Residents’ training will include focused education regarding the processes available to copy inpatient discharge letters that are sent to general practitioners to other relevant healthcare providers. This uses the same process within the electronic patient record as medical staff use to send letters following outpatient clinic appointments. This training will be” Source location Response from Manchester University 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 Improve Emergency Department HIVE discharge workflows so staff can send discharge letters to relevant healthcare providers, including external cardiology departments.
Verbatim wording from the response “As part of the rolling programme of improvements of the use of HIVE, the Trust is committed to improve the discharge process in our Emergency Departments to ensure that the workflow is seamless and our clinical teams are aware of the functionality to send copies of Emergency Department discharge letters to a full range of healthcare providers. This would include cardiology departments at providers such as the Royal Preston Hospital.” Source location Response from Manchester University NHS Foundation Trust
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9 May 2025 Janet Alison Anderson · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Failure of coordinated discharge planning and joint working between trusts View source Failure of documentation to capture key discussions and decisions View source Unavailability of acute hospital beds for patients needing acute care View source
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Janet Alison Anderson · 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
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
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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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of coordinated discharge planning and joint working between trusts
Wider context from the report “1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline.
She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge .
The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of documentation to capture key discussions and decisions
Wider context from the report “2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication . As a consequence, trust staff were not fully sighted on earlier decisions and her needs .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute hospital beds for patients needing acute care
Wider context from the report “3. The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting .
” Open source report
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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 escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
Verbatim wording from the response “Actions taken by MFT
MFT accept that the established escalation processes through the PTL meeting did not achieve timely discharge for Mrs Anderson. This was largely a result of the specific circumstances of her case, particularly the requirement for her to be accommodated outside her current local authority area. However, as a result of her case, discussions have been held with colleagues in GMMH to provide a more robust escalation process where discharge being organised by the CMHT is taking longer than expected.” Source location Response from Manchester University NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern about lack of joint working is disputed because the case was repeatedly discussed at daily meetings involving the relevant organisations.
Verbatim wording from the response “hospital but for whom there are other obstacles to discharge. This meeting is held daily and attended by representatives of the hospital, the Local Care Organisation (also part of MFT) and other relevant stakeholders including GMMH and the local authority.” Source location Response from Manchester University NHS Foundation Trust
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25 Sep 2024 Jyoti Rao · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Failure to allocate complex transplant patients a named consultant View source
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Jyoti Rao · Prevention of Future Deaths report
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Report summary
Jyoti Rao died at Tameside General Hospital on 20 February 2024 from hypoxic-ischaemic brain injury due to sepsis against a background of end-stage renal failure and failure of a transplanted kidney. Her death was also contributed to by traumatic nasogastric tube insertion. The principal concern was that complex transplant patients were not allocated a named consultant to support continuity of care and provide a longer-term view when complications arose.
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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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate complex transplant patients a named consultant
Wider context from the report “Whilst the court heard evidence as to the advantages of the ‘Consultant of the Week’ model in terms of team working, it is a matter of concern that complex transplant patients such as Miss Rao are not allocated a named consultant , who not only (in conjunction with others) can seek to ensure continuity of care is provided, but also who can take a longer-term view of the patient’s post-operative course and trajectory when complications arise .
” Open source report
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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 Provide complex renal transplant patients with dedicated outpatient appointments with a named transplant nephrologist responsible for continuity of care.
Verbatim wording from the response “In addition to this, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting.” Source location Response from Manchester University Hospitals NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transplant patients have a named responsible consultant: the surgeon who performed the transplant remains the lead consultant.
Verbatim wording from the response “For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant.” Source location Response from Manchester University Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Joint surgical and nephrology consultant-of-the-week cover provides safe and robust inpatient care without requiring individual consultant availability.
Verbatim wording from the response “For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant.” Source location Response from Manchester University Hospitals NHS Foundation Trust
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25 Jun 2024 John Howe · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to communicate changes in discharge timings to the ambulance service View source Failure to discharge patients within the required timing when they are unable to manage independently at home View source Failure to ensure factual accuracy in Serious Incident Review reports View source Delays in completing Serious Incident Reviews View source See 1 more concern
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John Howe · 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 Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.
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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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate changes in discharge timings to the ambulance service
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening. In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discharge patients within the required timing when they are unable to manage independently at home
Wider context from the report “(1) The inquest heard that there has been a change in policy with regards to the timing of discharge of patients from Manchester Royal Infirmary in circumstances where a patient is unable to manage independently when they arrive home. However, the Inquest heard that late discharges were still happening . In addition, the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure factual accuracy in Serious Incident Review reports
Wider context from the report “(2) Completion of the Serious Incident Review was delayed, and the report contained factual inaccuracies , giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing Serious Incident Reviews
Wider context from the report “(2) Completion of the Serious Incident Review was delayed , and the report contained factual inaccuracies, giving rise to a concern relating to the approach taken by Manchester City Council to Serious Incident Reviews.
” Open source report
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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 Share the draft Out of Hours Discharge Avoidance SOP with Wythenshawe Hospital and North Manchester General Hospital teams.
Verbatim wording from the response “MFT comprises of several adult hospital sites, and ambulance transport services are utilized across the organisation. The draft SOP has therefore also been shared with the teams at Wythenshawe Hospital and North Manchester General Hospital who have confirmed their intention to take it through their relevant governance structures to ratify and implement. I anticipate that this will prevent inconsistencies in discharge practices across the organisation, which could have led to challenges for external providers.” Source location Response from MFT
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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 Develop and progress the Out of Hours Discharge Avoidance SOP through MRI governance ratification for operational use.
Verbatim wording from the response “The MRI team have confirmed that a formal process for managing delayed discharges has now been developed via an “Out of Hours Discharge Avoidance” Standard Operating Procedure (SOP), which will be utilised as part of the operational application of the MFT Discharge Policy. Whilst this SOP is still in draft, it is due to be presented for ratification at the MRI Quality and Safety Committee on Tuesday 13th August 2024. For completeness a copy of the draft SOP has been enclosed within this correspondence.” Source location Response from MFT
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The second concern relates to Manchester City Council, so MFT will not provide a response.
Verbatim wording from the response “MFT was notified of the second concern outlined within the Regulation 28 report issued following the inquest, we understand that this relates to Manchester City Council and therefore no response is required from MFT on this matter.” Source location Response from MFT
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19 Jun 2024 Thomas Gibson · Prevention of Future Deaths report Manchester South
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Concerns raised 7 Lack of clear guidance for communication of test results and patient presentation across specialisms and team roles View source Lack of required senior review when diagnostic results are incongruous or unexpected in context View source Lack of minimum standards for obtaining clinical context when reviewing isolated test or investigation results View source Lack of authoritative national guidelines for ECG use and interpretation across clinical settings View source Failure to audit the sufficiency of detail in discharge summaries View source Failure to undertake wider audit of pre-discharge ECG interpretation in the Emergency Department and Acute Medical Unit View source Failure to undertake broader learning reviews of ECG misinterpretation and its clinical context View source See 4 more concerns
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Thomas Gibson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Gibson was found dead at home on 7 June 2023, with the death attributed to sudden cardiac death due to idiopathic myocardial fibrosis. Eleven days earlier, two ECGs were not recognised as showing complete heart block, and he was discharged from hospital. Concerns included inadequate communication and contextual review of test results, lack of senior review when findings were unexpected, insufficient auditing of ECG interpretation and discharge summaries, and the absence of authoritative national guidance on ECG use and interpretation.
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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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for communication of test results and patient presentation across specialisms and team roles
Wider context from the report “2. Having carefully considered all of the evidence at inquest, I am concerned that there does not appear to be clear guidance available to those working within the Trust as to what is required when communicating (particularly as to test results and a patient’s presentation) as between different specialisms and as between different roles within the 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of required senior review when diagnostic results are incongruous or unexpected in context
Wider context from the report “4. I am also concerned that there does not currently appear to be any particular requirement in place for a senior review of the patient to take place in circumstances where diagnostic tests undertaken yield results which appear incongruous / unexpected in the context of their presentation .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of minimum standards for obtaining clinical context when reviewing isolated test or investigation results
Wider context from the report “3. Connected with the above, I am concerned that the court heard evidence to the effect there is no specific guidance as to expected minimum standards as to obtaining appropriate context / information for clinicians (whether from the HIVE system or otherwise) when asked to review a single test or investigation result in isolation .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of authoritative national guidelines for ECG use and interpretation across clinical settings
Wider context from the report “1. The court heard evidence that ECGs are used by different professional groups in a wide range of clinical settings. A consultant cardiologist in this case gave evidence that complete heart block was sometimes a wholly incidental finding on ECG, with the patient not previously exhibiting any obvious signs or symptoms. In the present case, the court heard evidence that the computer-generated interpretations of two ECGs were both incorrect, and that three different (relatively experienced) doctors misinterpreted the ECGs. In those circumstances, I am concerned there are currently no authoritative national guidelines (such as those which exist for CTGs) in place as to the use and interpretation of ECGs in various clinical settings .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the sufficiency of detail in discharge summaries
Wider context from the report “6. It is a matter of concern that no audit as to the sufficiency of detail contained in discharge summaries appears to have been undertaken to date in the light of the issues identified by the Trust’s High Impact Learning Assessment.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake wider audit of pre-discharge ECG interpretation in the Emergency Department and Acute Medical Unit
Wider context from the report “5. Given the Trust’s own findings on investigation, I am concerned that no wider audit of ECGs interpreted in the Emergency Department / Acute Medical Unit prior to discharge of patients appears to have been undertaken ; and
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake broader learning reviews of ECG misinterpretation and its clinical context
Wider context from the report “1. Whilst some important learning has been derived from the Trust’s review of the care provided to Mr Gibson, I am concerned that a narrow focus on the error of three different doctors to interpret two ECGs correctly (rather than any broader consideration of the context in which such misinterpretations occurred) represents a missed opportunity to fully understand the factors that led to Mr Gibson’s discharge from hospital , thus creating a risk of future deaths.
” 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 Deliver regular ECG interpretation teaching and promote second opinions from appropriately qualified clinicians or cardiologists.
Verbatim wording from the response “ECG training is delivered regularly as part of the Wythenshawe medical teaching programme. The training also encourages junior members of the team and other Health Care Professionals (HCPs) to have a low threshold to seek a second opinion either from a Consultant/Specialist Trainee (who are signed off as competent to interpret ECGs independently) or cardiologist.” Source location Responses from NICE and MFT
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 Expand simulation and Human Factors training through a rolling programme for junior doctors across MFT sites.
Verbatim wording from the response “The concept of “human factors” in healthcare is described as “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”.² We are therefore expanding our simulation and Human Factors training. This HF training will form part of regular teaching programmes for medical and surgical junior doctors and the content and syllabus will be discussed with the HFA. The aim is to have a rolling 12-month programme established by 31 December 2024. This programme will look at how to provide training across MFT sites.” Source location Responses from NICE and MFT
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 Disseminate learning from missed opportunities and lessons through junior doctor teaching, governance meetings and mortality meetings.
Verbatim wording from the response “Acute Medicine and ED have weekly junior doctor teaching sessions. Once a month these are based on ‘missed opportunities’ or ‘lessons learnt’ from the previous month. This includes clinical cases or themes relating to errors to ensure learning is disseminated across the teams. Relevant cases are also added to the monthly governance meetings and mortality meetings which have a broader reach to include Consultants and senior nursing staff.” Source location Responses from NICE and MFT
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 Conduct the second phase of the ECG process audit to assess the impact of revised documentation and education.
Verbatim wording from the response “However, it was agreed that there would be benefit in performing an audit to ensure that the correct processes are being followed in ED with regard to the Standard Operating Procedure (SOP), i.e. ECG reviewed by the appropriately qualified member of staff with interpretation and action plan documented. This audit used data from timepoints in December 2023 with 64% of ECGs having an interpretation documented within the medical records. Of those not interpreted within the ED, some patients had opted to leave the department, and some had been under the care of specialties so not the direct responsibility of ED teams. Since that audit we have revised the SOP around documenting standards and delivered education on which patients should receive an ECG. The second phase of the audit will now take place to assess the impact of that intervention.” Source location Responses from NICE and MFT
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 Engage the Human Factors Academy to understand and mitigate factors contributing to incorrect ECG interpretation.
Verbatim wording from the response “1. The Trust has given careful consideration to this concern and apologises for giving the impression of a narrow focus. The Trust is aware that there is a longstanding issue with ECG interpretation both within the UK and internationally. Multiple studies have confirmed that the accuracy of ECG interpretation varies from 42% for medical students and 75% for cardiologists (who are the experts at interpreting ECGs).¹ These issues with ECG interpretation are present even after extensive training and other interventions. For this reason, we have focused on the Human Factors errors in clinical medicine and have engaged with our Human Factors Academy (HFA). This will support us to understand better the other factors at play which contribute to incorrect ECG interpretation; and which can be mitigated in the future.” Source location Responses from NICE and MFT
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 A random audit of selected ECGs is considered unable to provide assurance about interpretation quality.
Verbatim wording from the response “5. As stated above, it is well documented that ECG interpretation accuracy varies between 42% and 75% (expert cardiologists) and so it has been agreed by the Clinical Head of Division and the WTWA Associate Medical Director for Quality and Patient Safety that performing a random audit of selected ECGs would not provide assurance of the quality of interpretation. The only way to seek assurance would be to audit all ECGs and this would be extremely onerous on the ED department and distract from delivery of patient care. An audit presented in August 2024 has shown that we perform 100–190 ECGs every day in ED which amounts to 41% of all attendees. Of these ECGs, 35–56% of them have an abnormality detected.” Source location Responses from NICE and MFT
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 Registrar review is considered an appropriately senior arrangement, so consultant oversight of every ECG is not considered reasonable.
Verbatim wording from the response “4. Whilst no Consultant reviewed the ECG prior to Mr Gibson being discharged, the Registrars did review this. A Registrar is an appropriately senior clinician to discharge a patient; it is not anticipated or reasonable for a Consultant to oversee all ECG interpretation 24 hours a day, as the opportunity cost of this would adversely impact other activity that necessitates Consultant input.” Source location Responses from NICE and MFT
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 Auditing all Emergency Department ECGs is considered excessively onerous and likely to distract from patient care.
Verbatim wording from the response “5. As stated above, it is well documented that ECG interpretation accuracy varies between 42% and 75% (expert cardiologists) and so it has been agreed by the Clinical Head of Division and the WTWA Associate Medical Director for Quality and Patient Safety that performing a random audit of selected ECGs would not provide assurance of the quality of interpretation. The only way to seek assurance would be to audit all ECGs and this would be extremely onerous on the ED department and distract from delivery of patient care. An audit presented in August 2024 has shown that we perform 100–190 ECGs every day in ED which amounts to 41% of all attendees. Of these ECGs, 35–56% of them have an abnormality detected.” Source location Responses from NICE and MFT
Open published response
16 May 2023 Benedict Peters · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of policy or protocol governing discharge from the Ambulatory Care Unit without medical review View source Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit 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
Benedict Peters · 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
Benedict Peters was found dead at his parents’ home on 12 November 2022, after being discharged from the Manchester Royal Infirmary Ambulatory Care Unit the previous day following assessment for chest pain, shortness of breath, sore throat and an aching arm. The inquest found that he died from haemopericardium and acute aortic dissection, with a narrative conclusion referring to complications from an undiagnosed underlying heart defect. Concerns included his discharge without an in-person doctor’s review despite his symptoms, age and family history, and the absence of a Trust policy or protocol governing such discharges.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or protocol governing discharge from the Ambulatory Care Unit without medical review
Wider context from the report “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor.
It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit
Wider context from the report “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor .
It is a further matter of concern that (according to the evidence of ████████, Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place.
” Open source report
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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 Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.
Verbatim wording from the response “Mr Peters had been seen and assessed by a Physician Associate (PA), these are professional practitioners working under the aegis of the Royal College of Physicians of London which has produced guidance regarding their responsibilities and scope of practice (https://www.rcplondon.ac.uk/news/fact-finding-physician-associates). Within Manchester University NHS Foundation Trust (MFT), PAs work within an agreed governance framework (enclosed). This has the effect that PAs are not independent practitioners (paragraph 12.7) but work under the delegated authority of a consultant (paragraph 14.2). It is the responsibility of the supervising consultant to ensure that the level of supervision is appropriate to the knowledge and skills of each individual PA.” Source location Response from Manchester University NHS Foundation Trust
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 Existing policy requires medical authorisation for Ambulatory Care Unit discharge and prevents Physician Associates from discharging patients independently.
Verbatim wording from the response “2) “No policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place”” Source location Response from Manchester University NHS Foundation Trust
Open published response
17 Aug 2022 Dr Lee Winslow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to reconsider external referrals after discovering continued private practice during NHS sick leave View source Failure to formally refer medicine misappropriation involving self-harm risk to the General Medical Council View source Failure to use a multidisciplinary approach with independent oversight for serious medicine misappropriation cases View source Lack of meaningful external review of cases involving serious medicine misappropriation View source Failure to formally refer medicine misappropriation involving self-harm risk to the Police 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
Dr Lee Winslow · 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
Dr Lee Winslow was found dead at home on 12 June 2021 after taking medication with the intention of ending his life; the inquest concluded that he died from toxicity and recorded suicide. The report raises concerns that, after his earlier suicide attempt and admission to taking medicines from Trust stocks, the case was not formally referred to the Police or General Medical Council, and that decisions were made without meaningful external or multidisciplinary review.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reconsider external referrals after discovering continued private practice during NHS sick leave
Wider context from the report “2. In December 2020, the Trust became aware that, whilst on sick leave from the NHS, Dr Winslow had continued with his private practice notwithstanding an explicit instruction from his manager to the effect that he should refrain from all work. It is a further matter of concern that this development did not, of itself, cause the Trust to reconsider its position and make the referrals set out above ;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally refer medicine misappropriation involving self-harm risk to the General Medical Council
Wider context from the report “1. Following the admission by Dr Winslow in 2020 that he had taken medicines from the Trust with a view to ending his life, it is a matter of concern that the case was not formally referred to the Police and the General Medical Council .
Making such referrals would have had the potential benefit of:-
i) Providing the Trust with ready access to external advice as to the adequacy (or otherwise) of steps taken to mitigate the future risk of staff members misappropriating medicines with a view to self-harming; and
ii) Offered access to a mechanism whereby objective analysis of Dr Winslow’s fitness to practise as a Consultant Anaesthetist (both from a health and broader perspective) could have taken place;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a multidisciplinary approach with independent oversight for serious medicine misappropriation cases
Wider context from the report “3. In the absence of any meaningful external review of the case as a whole, it is a particular concern that most of the actions which followed the theft of medication by Dr Winslow in 2020 appear to have been taken as a result of decisions made by members of the Trust’s medical hierarchy.
In view of the gravity of the issues raised by Dr Winslow’s misappropriation of drugs in 2020, and the previous suicide of a Consultant Anaesthetist employed by the Trust involving the misuse of prescription medicines, it is a matter of concern that a more multi-disciplinary approach was not taken , perhaps overseen by someone such as a non-executive director of the organisation .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful external review of cases involving serious medicine misappropriation
Wider context from the report “3. In the absence of any meaningful external review of the case as a whole , it is a particular concern that most of the actions which followed the theft of medication by Dr Winslow in 2020 appear to have been taken as a result of decisions made by members of the Trust’s medical hierarchy .
In view of the gravity of the issues raised by Dr Winslow’s misappropriation of drugs in 2020, and the previous suicide of a Consultant Anaesthetist employed by the Trust involving the misuse of prescription medicines, it is a matter of concern that a more multi-disciplinary approach was not taken, perhaps overseen by someone such as a non-executive director of the organisation.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally refer medicine misappropriation involving self-harm risk to the Police
Wider context from the report “1. Following the admission by Dr Winslow in 2020 that he had taken medicines from the Trust with a view to ending his life, it is a matter of concern that the case was not formally referred to the Police and the General Medical Council.
Making such referrals would have had the potential benefit of:-
i) Providing the Trust with ready access to external advice as to the adequacy (or otherwise) of steps taken to mitigate the future risk of staff members misappropriating medicines with a view to self-harming; and
ii) Offered access to a mechanism whereby objective analysis of Dr Winslow’s fitness to practise as a Consultant Anaesthetist (both from a health and broader perspective) could have taken place;
” 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 Convene documented senior-level Trust–GMP meetings to standardise and monitor protocols and information-sharing.
Verbatim wording from the response “including plans to implement such change. As previously highlighted, the Trust is setting up a regular liaison meeting with the GMP where we can discuss matters with the Police. By way of an update, from October 2022 the Trust and GMP will be convening regular, documented, senior level meetings to ensure protocols and information-sharing arrangements between the two organisations are standardised and monitored. These meetings will review a range of touch points between the two organisations including, but not exclusive to, the reporting, management, and investigation of crime; ‘missing from homes’; and emergency responses. The aim of these meetings will be to ensure that collectively the safety of the public and patients is prioritised through the appropriate implementation of agreed protocols.” Source location Response from Manchester University 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 Reinforce staff processes requiring early Pharmacy involvement after medicine-misappropriation incidents and timely engagement with the Controlled Drugs Liaison Team.
Verbatim wording from the response “In addition to this, our Pharmacy team has strong working relationships with the local Controlled Drugs Liaison team (CDLT) who I understand provides invaluable support and guidance in matters concerning medicines management and misappropriation. We are reiterating that all staff must adhere to our internal processes to ensure Pharmacy are involved at the earliest possible opportunity following any incidents concerning medicine misappropriation and reinforcing processes to ensure the CDLT are in turn involved in a timely manner.” Source location Response from Manchester University NHS Foundation Trust
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 The Trust disputes that the later private-practice incident failed to prompt reconsideration, stating that it informed the GMC and received support.
Verbatim wording from the response “2. In December 2020, the Trust became aware that, whilst on sick leave from the NHS, Dr Winslow had continued with this private practice notwithstanding an explicit instruction from his manager to the effect that he should refrain from all work. It is a further matter of concern that this development did not, of itself, cause the Trust to reconsider its position and make referrals as set out above.” Source location Response from Manchester University NHS Foundation Trust
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 A police referral was not considered necessary because criminalisation could worsen the vulnerable doctor's mental health without evidence of patient harm or other criminality.
Verbatim wording from the response “A formal referral to Greater Manchester Police (GMP) was not considered necessary following Dr Winslow’s extremely serious, nearly ‘successful’ suicide attempt on 26 August 2020, when it was subsequently determined that he had in all likelihood misappropriated the medications used in this attempt from the Trust.” Source location Response from Manchester University NHS Foundation Trust
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 An external case review or non-executive oversight was considered inappropriate because the Trust's multidisciplinary medical and human-resources arrangements provided suitable decision-making.
Verbatim wording from the response “It would be outside of usual practice to have an external review in this matter.” Source location Response from Manchester University NHS Foundation Trust
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 The Trust considered further formal GMC referral unnecessary because the established Employer Liaison mechanism provided external advice and local health management was agreed.
Verbatim wording from the response “aspect to continue to be managed locally. In relation to the doctor’s conduct, the GMC would await the outcome of the investigation around working in the private sector on multiple occasions when off sick, before making any decision on this aspect.” Source location Response from Manchester University NHS Foundation Trust
Open published response
27 Jan 2021 Norma Bradbury · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Delays in transmitting discharge letters when timely GP involvement is required 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
Norma Bradbury · 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
Norma Bradbury underwent aortic valve replacement on 15 February 2019, was discharged home on 22 February, and was found deceased beside her bed on 3 March 2019. The report identified concern that the discharge letter, which required GP involvement within one week to check bloods and blood pressure and restart and titrate Losartan, was not received until 25 February. The medical cause of death was recorded as intracerebral haemorrhage, with systemic hypertension and oral anticoagulation for atrial fibrillation contributing.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transmitting discharge letters when timely GP involvement is required
Wider context from the report “Mrs Bradbury was discharged on 22.02.19.
The discharge letter to her GP instructed a review within 1 week to check Mrs Bradbury’s bloods and blood pressure, and to restart Losartan, and titrate the dose to her blood pressure. The consultant giving evidence at the hearing was clear that he expected this to have commenced within a week of discharge.
The evidence of Mrs Bradbury’s GP was that the discharge letter was not received until 25.02.19. The GP also advised that the delay in receiving discharge letters was very variable, between days and weeks.
I accept that in many cases the discharge letter is no more than a summary of an attendance and requires little or no further action on the part of the GP and the delay is of no consequence. However, where, as here, the discharging hospital requires GP involvement within 1 week of discharge a delay of 3 days in requesting or advising that involvement is not acceptable.
While it was not possible to determine any difference in outcome in Mrs Bradbury’s case there is a risk that such a delay would make a difference.
” Open source report
7 Oct 2020 Alison Jean Shirley Jeanes · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to manage differences between haematology and neurosurgical recommendations View source Lack of a system to fast track CT scans for patients on warfarin with suspected head injury View source Delays in obtaining and chasing up specialist neurosurgical input View source Failure to obtain and follow up further haematology advice when INR remains above target View source See 1 more concern
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
Alison Jean Shirley Jeanes · 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
Alison Jean Shirley Jeanes was admitted to hospital after an accidental fall at a care home while taking anticoagulation, with a head injury and high INR. She later developed a progressing bleed, was placed on palliative care, and died in hospital. The report raised concerns about delays in neurosurgical input, CT scanning, and further haematology advice, and about unclear responsibility for follow-up.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage differences between haematology and neurosurgical recommendations
Wider context from the report “3. The inquest heard that haematology advice on the day of admission was to reduce her INR. This advice was reconfirmed by the neuro surgeons the following day. There were differences in the recommendations and it was not entirely clear how that difference was being managed. In any event despite repeated attempts with Vitamin K Mrs Jeanes INR remained above the target. Further advice from the haematologist was not sought until 26th March some 9 days after her admission. It was unclear why that delay had occurred as the notes suggested it had been recognised that advice should have been sought previously but this had not been followed up. There was no evidence before the inquest of what system was in place or who would take responsibility for follow up in such a situation.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to fast track CT scans for patients on warfarin with suspected head injury
Wider context from the report “2. Mrs Jeanes was brought into hospital by ambulance at the direction of a GP who recognised that she had a suspected head injury and was on warfarin. The GP recognised that the NICE guidance suggests there is an 8 hour window for patients on warfarin with a suspected head injury. Her fall had been at 23.58 on 16th March. The inquest heard that she was triaged but her CT scan was not expedited and was not reported on until 11.45 almost 12 hours after the fall . There was no evidence of a system that would fast track such cases for a CT scan .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining and chasing up specialist neurosurgical input
Wider context from the report “1. The inquest heard that whilst contact was made with the Neurosurgical team at Salford Royal Hospital on the day of her admission there was no conversation with a Doctor from that team until the day after her admission . As a result there was no expert neuro input into her care for 24 hours. There was no evidence that there was any attempt to chase up contact earlier .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and follow up further haematology advice when INR remains above target
Wider context from the report “3. The inquest heard that haematology advice on the day of admission was to reduce her INR. This advice was reconfirmed by the neuro surgeons the following day. There were differences in the recommendations and it was not entirely clear how that difference was being managed. In any event despite repeated attempts with Vitamin K Mrs Jeanes INR remained above the target. Further advice from the haematologist was not sought until 26th March some 9 days after her admission . It was unclear why that delay had occurred as the notes suggested it had been recognised that advice should have been sought previously but this had not been followed up . There was no evidence before the inquest of what system was in place or who would take responsibility for follow up in such a situation.
” 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 Embed the Clinical Decision Support Tool in the Emergency Department Electronic Patient Record to guide adult head injury management and CT requirements.
Verbatim wording from the response “I also enclose the “Clinical Decision Support Tool”, which contains a user friendly flow chart for use when assessing and treating adult patients presenting with head injuries, which covers the requirements around CT head scans being undertaken according to the patient’s risk category, as well as the circumstances in which advice should be sought from Salford Royal Hospital’s Neurosurgery team based on abnormality on the imaging. This tool is embedded within the Electronic Patient Record system used by clinicians in the Emergency Department as decision support software.” Source location 2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
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 Use the updated Emergency Department adult head injury pathway to guide assessment, CT scanning, neurosurgical referral and clinical documentation.
Verbatim wording from the response “Emergency Department Head Injury Pathway
I enclose the recently updated (in August 2020) local head injury pathway in place at Wythenshawe Hospital’s Emergency Department, for use by clinical staff when assessing adult patients for a head injury and for documenting the assessment in the patient’s clinical notes. This local pathway is in line with NICE guidance and serves to guide clinicians as to the steps to be undertaken to ensure a comprehensive assessment of patients presenting with a head injury. The local pathway specifically covers the indications for a CT scan and/or to contact the Neurosurgical specialists for advice and provides the template for documenting the outcome of CT scan/Neurosurgical advice in the clinical notes.” Source location 2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
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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 Salford Royal’s neurosurgical team provided advice on the same day, contrary to the apparent inquest conclusion that advice took 24 hours.
Verbatim wording from the response “Neurosurgical Advice from Salford Royal Hospital
Mrs Jeanes was referred to the Neurosurgical Coordinator on 17th March 2020, and the referral was followed up the next day. We have liaised with colleagues at Salford Royal NHS Foundation Trust; ████████, Chief Officer and Medical Director, and ████████, Clinical Director for Surgical Neurosciences. Having looked into this further, it appears that the standard of the record-keeping at Wythenshawe Hospital may have been such that when you heard evidence at the Inquest this gave rise to an incorrect assumption that the Neurosurgical team took a day to provide a plan, however from review of the records held by Salford Royal Hospital colleagues, it appears advice was in fact provided by Salford Royal Hospital Neurosurgical colleagues the same day that this was requested.” Source location 2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
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 Existing 24-hour haematology support, anticoagulation guidance and ward-team responsibilities provide arrangements for INR management and follow-up.
Verbatim wording from the response “Advice from Haematology
The requirement is that the on-call or ward team should contact the Haematology specialists at Wythenshawe Hospital should they require advice. Patients should then be referred back to the Anticoagulant Clinic on discharge from hospital for follow-up care. The Trust has a Haematology service which is on-call 24 hours a day, 7 days a week. The Haematology team will advise on appropriate reversal of anticoagulation. It is the ward team’s responsibility to follow-up and action such advice, and to refer back to Haematology should further specialist input be needed in the course of the patient’s admission.” Source location 2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
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 The local head injury pathway and electronic decision-support tool provide existing guidance for timely CT scanning and neurosurgical referral.
Verbatim wording from the response “Emergency Department Head Injury Pathway
I enclose the recently updated (in August 2020) local head injury pathway in place at Wythenshawe Hospital’s Emergency Department, for use by clinical staff when assessing adult patients for a head injury and for documenting the assessment in the patient’s clinical notes. This local pathway is in line with NICE guidance and serves to guide clinicians as to the steps to be undertaken to ensure a comprehensive assessment of patients presenting with a head injury. The local pathway specifically covers the indications for a CT scan and/or to contact the Neurosurgical specialists for advice and provides the template for documenting the outcome of CT scan/Neurosurgical advice in the clinical notes.” Source location 2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
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 The CT scan reporting delay was one hour beyond target but did not appear to have significantly contributed to the adverse outcome.
Verbatim wording from the response “After the request was submitted by the ward at 08.32 hours, Mrs Jeanes attended Radiology and the scan was performed at 09.16 hours, i.e. within 44 minutes. This is within the required Key Performance Indicator (KPI)/target for imaging of this nature, which requires that for patients in the Emergency Department with a head injury, the required turnaround time from the scan being requested to being performed should be within an hour. The time from the scan being undertaken to a verified CT scan report being provided was two hours, with the report being verified at 11.16 hours, which the Radiology team accepts is one hour outside of the required KPI/target, according to which it is expected that CT scans of this nature requested by the Emergency Department are to be reported within an hour of the examination.” Source location 2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
Open published response
28 Sep 2020 Mr William Ivan McKibbin · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of documentation checks confirming bed brakes are on View source Failure to maintain a culture in which staff can speak up about errors and poor practice View source Lack of a minimum-information standard for cross-hospital specialist advice communication View source Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations View source Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths View source Unavailability of medical records across Trust hospital sites View source Lack of documentation checks confirming bed-rails are in the appropriate position 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
Mr William Ivan McKibbin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from deaths.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation checks confirming bed brakes are on
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position, and the bed brakes are on .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a culture in which staff can speak up about errors and poor practice
Wider context from the report “1. The evidence heard at this inquest left me with residual concerns as to the prevailing culture at the Trust, and by extension, within the NHS .
It was clear from the evidence that by the time of Mr McKibbin’s death, Managers from the Trust were aware at the very least that the brakes simply cannot have been applied to his bed at the time he sustained the fall which led to his death.
Despite this, no confirmation of this fact was made to Mr McKibbin’s family, or in the report of his death to the Coroner. Similarly, this conclusion was not drawn by a number of internal investigations undertaken by the Trust, or indeed in evidence given to the court by Professor ████████, Chief Nurse and a member of the Trust’s board.
For a duty of candour to have meaning, it is essential the prevailing culture of an organisation is one where staff have freedom to speak out. For the reasons set out by Sir ████████ QC in his PFD Report into events at Mid Staffordshire NHS Foundation Trust, unless staff of all levels feel able to speak up about their own errors, and to point out to highlight poor practice of others, a significant risk of future deaths will remain .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a minimum-information standard for cross-hospital specialist advice communication
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital .
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations
Wider context from the report “4. In view of the importance of robust and reliable investigations into clinical incidents to reducing the risk of future deaths, it is a matter of concern that no guidance currently exists for on-call managers and investigators as to quickly identifying, securing and gathering relevant evidence .
Improvements in gathering evidence would assist the Trust in reliably identifying the underlying cause or causes of incidents, which in turn would better inform actions to be taken with a view to reducing the risk of future deaths.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths
Wider context from the report “5. In order to enhance learning from deaths, consideration should be given to modifying the Statutory Notification process following death of a service-user so as to require Registered Providers to lodge specified relevant evidence as to how the death occurred within a defined period .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of medical records across Trust hospital sites
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital.
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation checks confirming bed-rails are in the appropriate position
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position , and the bed brakes are on.
” 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 Review nursing documentation and its effectiveness in supporting individualized care plans through a Trust Task and Finish Group with academic partners.
Verbatim wording from the response “The Falls Collaborative Research Sub-Group, co-chaired by the Trust’s Group Deputy Chief Nurse and international expert Professor ████████, Director of the National Institute for Health Research’s Older People & Frailty Policy Research Unit, has reviewed and approved the Trust’s Intentional Rounding documentation. The evidence base for rounding was considered at the Falls Collaborative meeting on 21ˢᵗ September 2020. Subsequently, a Task & Finish Group has been established within the Trust with support from academic partners to review the current nursing documentation and its effectiveness in contributing to the delivery of an individualised care plan for patients. A high-level literature review has been conducted on intentional rounding to inform this work programme.” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
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 Establish a Trust-wide electronic patient record, with implementation work underway toward the planned September 2022 go-live.
Verbatim wording from the response “The matter of the clinical record is a valid concern and one that the Trust has recognised. To that end we have a detailed assessment of the risk and have been working with teams widely on the mitigation of the risks associated with paper and electronic records across our hospitals and services.” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
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 Use the newly developed First Responder document Trust-wide for every inpatient fall to record the immediate scene and required post-fall information.
Verbatim wording from the response “In addition, in response to the learning arising out of the review of Mr McKibbin’s care, a First Responder document has been developed and brought into use Trust-wide from September 2020, included as part of the updated Falls Investigation template. This document has been designed to support staff in investigating the immediate scene following an inpatient fall. Key considerations for completion of the First Responder document have been disseminated to staff using the “Feedback Friday” campaign. This has included communicating that the First Responder document must be completed for all falls, even where patient harm is not suspected.” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update falls documentation and policy to require immediate scene checks, bed-brake and bed-rail checks, falls-risk review, and appropriate care planning during intentional rounding.
Verbatim wording from the response “The intentional rounding core documentation (attached at appendix 4) was adapted alongside the Trust’s Inpatient Falls Management Policy, Falls Care Plan, and Falls Investigation Template, with changes publicised via the Trust’s iNews communication on 9ᵗʰ September 2020 which included a spotlight on falls prevention and management. The updates to documentation were also circulated by the Group Deputy Chief Nurse on 11ᵗʰ September 2020. The changes were also highlighted specifically at Trafford General Hospital via the site Falls Specialist Nurse, with a poster and publicity campaign.” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
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 Concerns about the wider NHS culture fall outside the Trust’s ability to comment; its response addresses culture within the Trust and Trafford General Hospital.
Verbatim wording from the response “Whilst I cannot comment on the concerns about the wider NHS, I am confident that at a Trust level and locally at Trafford General Hospital the prevailing culture is one of openness and transparency. I am deeply sorry, as stated earlier, that the substandard management of the investigation and the poor communication with Mr McKibbin’s family left them and yourself with a different view. It is clear that the delays in sharing the report resulted in a lack of timely openness on our part but we sought to be honest at all times.” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
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 The Trust disputes that managers knew the bed brakes were not applied, stating the unwitnessed fall and absent contemporaneous checks prevented that conclusion.
Verbatim wording from the response “I share your concern that the assessment of the brakes was not undertaken immediately post Mr McKibbin’s fall. I also accept in full your findings in relation to the report completed, it was not of the quality I would expect and lacked some key questions and lines of enquiry. Those failings acknowledged; it is not accepted that the Managers from the Trust therefore knew the brakes could not have been on. Sadly, Mr McKibbin’s fall was unwitnessed and, as confirmed, the brakes were not checked at the time. The Trust position on this was that it could not be ascertained as to whether the brakes were on and that the bed rails were applied. I would draw your attention to page 4 of the report where it is noted that “Upon entering the room Mr” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
Open published response
27 Apr 2020 Evelyn Ross · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to follow falls risk policy View source Failure to maintain sufficiently detailed clinical documentation View source Lack of a clear system of regular orthogeriatric consultant reviews View source Delays in arranging suitable community care packages for discharge View source Failure to escalate deterioration to a consultant View source Lack of sufficient and appropriately experienced ward staffing View source See 3 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. 16
Action
Maintain enhanced falls oversight through care reviews, live documentation audits, bay tagging, senior nursing checks, intentional-rounding projects, and falls-equipment compliance monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide enhanced induction and senior nursing support for new and temporary staff, including local clinical-area induction.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Review out-of-hours skill mix and training needs and coordinate regular senior nursing deployment meetings with escalation of staffing concerns.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Audit falls-risk assessments and policy compliance through ward, hot-spot, Matron, Trust-wide, and annual accreditation reviews.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Review Ward 6 workforce establishments and progress collaborative workforce redesign with therapy leads to align staffing and skill mix with rehabilitation needs.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Relaunch staff competency checklists and falls-management prompts across WTWA to identify training needs and support guided reflection.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Amend the falls policy to require documented 24-hour review of individualised additional interventions, obtain ratification, and disseminate the update across the Trust.
Stated plannedThe respondent said that this action was planned when they made their response on 5 June 2020. View source
Action
Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Operate falls harm-review and Harm-Free Care meetings to investigate falls, identify learning, implement preventative measures, and monitor compliance.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide Ward Managers with falls-risk-reduction checklists and prompts to support consistent assessment, care planning, and management.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Use the updated falls policy, electronic risk-assessment records, Ward 6 and hospital falls action plans, and multidisciplinary task groups to coordinate falls prevention.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Recruit registered and unregistered nurses, appoint Ward 6 leadership and patient-flow staff, and recruit additional Nursing Assistants to strengthen staffing capacity.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Deliver falls-risk training and support, including Hot Topic sessions, face-to-face education, and mandatory interactive e-learning for clinical staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.
Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source See 13 more actions
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AI-generated summary
Evelyn Ross · 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 Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow falls risk policy
Wider context from the report “4. The inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficiently detailed clinical documentation
Wider context from the report “3. During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system of regular orthogeriatric consultant reviews
Wider context from the report “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging suitable community care packages for discharge
Wider context from the report “2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate deterioration to a consultant
Wider context from the report “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient and appropriately experienced ward staffing
Wider context from the report “1. The inquest was told that the ward in question had been short staffed for a number of months . As a result there was a reliance on agency staff and less experienced staff . The trust was now seeking to resolve the issue but it was still not fully resolved . It reflected a wider issue of a national shortage of nurses.
” 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 Maintain enhanced falls oversight through care reviews, live documentation audits, bay tagging, senior nursing checks, intentional-rounding projects, and falls-equipment compliance monitoring.
Verbatim wording from the response “A number of initiatives are already in place at Trafford General Hospital to ensure oversight of falls across the hospital including Matrons/Lead Nurse completing their enhanced care reviews three times per week as per policy, live documentation audits, relaunching the Bay Tagging initiative on hot spot areas and firmly challenging staff who do not adhere to policy, quality improvement projects in relation to intentional rounding and increased daily senior nursing on clinical areas to ensure correct adherence to Enhanced Observations of Care Policy and proper use of falls sensor equipment.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
Verbatim wording from the response “In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local ‘Discharge Policy for Adult Inpatients (excluding Children and Maternity)’, implemented May 2019, a copy of which is enclosed (Appendix 1). At the Trust’s WTWA site this policy is overseen by the Integrated Discharge team. The policy is applicable to all Trust staff who are involved in the assessment, planning and monitoring of patient discharges. It also applies to staff from other health/social care organisations involved in the discharge” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 enhanced induction and senior nursing support for new and temporary staff, including local clinical-area induction.
Verbatim wording from the response “Induction for new recruits is provided on the Trafford General Hospital site, and the Head of Nursing now supports this with the welcome and introduction session. This provides an additional opportunity for staff to engage with Senior Nurses who give feedback and provide ongoing support.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Review out-of-hours skill mix and training needs and coordinate regular senior nursing deployment meetings with escalation of staffing concerns.
Verbatim wording from the response “A review of the skill mix and roles and a Training Needs Analysis for the Out of Hours team has also been undertaken. This is to ensure that the clinical contribution is maximised, and the correct level of professional leadership is provided to teams at Trafford General Hospital in the out of hours period.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Audit falls-risk assessments and policy compliance through ward, hot-spot, Matron, Trust-wide, and annual accreditation reviews.
Verbatim wording from the response “As part of the Monthly Matron Review proforma, a sample of patient assessments are audited to monitor the ongoing completion of Falls Risk Assessments. Results of these audits are highlighted at the Monthly Matron Confirm and Challenge meetings with Ward Managers.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Review Ward 6 workforce establishments and progress collaborative workforce redesign with therapy leads to align staffing and skill mix with rehabilitation needs.
Verbatim wording from the response “The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine safe staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and January 2020. The outcome of this data collection was utilised to inform the establishment review process, which was completed for Ward 6 in March 2020. Further workforce redesign is being progressed collaboratively with Therapy Leads for Ward 6, to reflect the requirements of the rehabilitation service at Trafford General Hospital.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Relaunch staff competency checklists and falls-management prompts across WTWA to identify training needs and support guided reflection.
Verbatim wording from the response “In addition to these assurance processes, senior nursing teams across WTWA are being asked to relaunch both the Staff Competency Checklist for the Risk Reduction and Management of Inpatient Falls, and the Falls Risk Reduction and Management Prompts, to ensure staff feels comfortable and confident in falls risk assessment and care planning; and that additional training needs are highlighted appropriately. This process also allows for staff managing individuals involved in falls incidents to consider their competency level and ensure guided reflection is appropriately provided.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Amend the falls policy to require documented 24-hour review of individualised additional interventions, obtain ratification, and disseminate the update across the Trust.
Verbatim wording from the response “When a nursing review of Mrs Ross’ care was undertaken prior to the Inquest, it was identified that the individualised additional intervention section of the falls care plan were not reviewed every 24 hours. It was noted however that at the time there was a discrepancy in the Trust falls policy which did not specifically refer to a requirement to undertake this, and document this review every 24 hours. Subsequently, the Falls Specialist Nurse was made aware of the discrepancy in the falls policy. This amendment to the policy has been incorporated with further updates to the policy (to reduce the need for multiple policy revisions being shared with staff intermittently, and to provide one comprehensive update).” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
Verbatim wording from the response “Training is provided to all clinical staff in respect of documentation in clinical records. As part of the mandatory induction of all staff, Trust training is provided in respect of Information Governance, which covers accurate and clear record keeping. This is also covered in the mandatory training updates which all staff are required to undertake every two years. All staff also receive a local induction in their own area of work which comprehensively covers all areas of documentation and records keeping relevant to the individual staff member’s role. The Trust retains records of all staff training undertaken Trust-wide, including mandatory training.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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 Operate falls harm-review and Harm-Free Care meetings to investigate falls, identify learning, implement preventative measures, and monitor compliance.
Verbatim wording from the response “Falls resulting in patient harm are presented to the monthly Falls Accountability meeting. Thematic analysis is considered in order to establish learning arising out of patient incidents in respect of falls and to implement preventative measures to improve patient safety.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Provide Ward Managers with falls-risk-reduction checklists and prompts to support consistent assessment, care planning, and management.
Verbatim wording from the response “Each individual Ward Manager has been provided with a checklist to support falls risk reduction, as well as falls reduction and management prompts.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Use the updated falls policy, electronic risk-assessment records, Ward 6 and hospital falls action plans, and multidisciplinary task groups to coordinate falls prevention.
Verbatim wording from the response “Prior to Mrs Ross’ admission, the Trust had recently, in April 2019, implemented a new Trust-wide updated Falls Management Policy and I enclose a copy of this for your information (Appendix 2). I am very sorry to hear that there was evidence that aspects of the falls policy were not adhered to in Mrs Ross’ case.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Recruit registered and unregistered nurses, appoint Ward 6 leadership and patient-flow staff, and recruit additional Nursing Assistants to strengthen staffing capacity.
Verbatim wording from the response “Since April 2019, a number of International Recruitment (IR) Registered Nurses have been recruited to wards at Trafford General Hospital in addition to successful domestic recruitment to Registered Nursing posts across Trafford General Hospital. A substantive appointment was made for a new Ward Manager that joined the team in January 2020, in addition four experienced Band 6 Registered Nurses have been appointed to Ward 6 specifically. A Band 3 Patient Flow Coordinator role has also been developed and successfully appointed to on Ward 6.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Deliver falls-risk training and support, including Hot Topic sessions, face-to-face education, and mandatory interactive e-learning for clinical staff.
Verbatim wording from the response “As of April 2020, the Matron for Quality Improvement and Patient Experience’s compliance audit for falls risk assessment completion and falls care plan implementation was 90%. Hot Topic Sessions covering falls risk reduction and management have been launched in June 2020. So far this month across Trafford General Hospital 30 members of staff, including six members of staff from Ward 6, have attended the training, with several further sessions to take place this month to capture further staff.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
Verbatim wording from the response “As stated above, a Patient Flow Coordinator role has been developed and successfully appointed to Ward 6 at Trafford General Hospital. In addition, the Hospital Discharge Service is available and responsible for supporting wards in the discharge process of patients, and their input is routinely sought for instance in respect of patients who require special considerations or who may have complex support needs on discharge. The discharge service will assist the ward staff to plan and identify the supporting needs of the patient for discharge.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.
Verbatim wording from the response “The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily at the morning Board Rounds and all patients are discussed and followed up to Consultant level as needed. If clinical concerns are raised in respect of an individual patient’s case, a member of the Senior Medical team (Consultant or Registrar) will review the patient.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.
Verbatim wording from the response “In line with usual practice in secondary care, patient discharges from hospital are in some cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions by other bodies such as Local Authorities; for instance assessments in respect of any ongoing package of care required in the community, as well as other bodies in the Social Care sector. It is the Trust’s responsibility to undertake such liaison where applicable to ensure arrangements are in place so that the Trust can effect a safe patient discharge to the community. Given the Trust’s dependence on other parties in respect of this, delays can occur, and this is unfortunately an NHS-wide issue not unique to our Trust. Safe discharge requires teamwork across many people and organisations.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.
Verbatim wording from the response “centre placement was declined by the Local Authority; in order for the clinical team to progress her discharge, as I am sure you will appreciate, there was a limitation on further actions the Trust was able to take to address this issue, due to its dependence on actions by In-reach, Social Care and other bodies.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.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 concluded that regular Consultant reviews occurred and junior doctors escalated clinical concerns as required in Mrs Ross’ case.
Verbatim wording from the response “Having undertaken a comprehensive review of the entries in Mrs Ross’ clinical notes, the Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case there were in fact regular Consultant reviews, in line with required standards, and there was no issue in respect of junior doctor escalation, which as documented in the clinical notes took place as required. I apologise if the evidence you heard at the Inquest did not accurately convey this.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
7 Nov 2019 Charlotte Elizabeth Jacobs · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 5 Unavailability of completed guidance and protocol for transfers from Manchester Royal Infirmary to Park House View source Failure of relevant staff to be aware of internal investigation findings View source Risk of further inappropriate discharges or transfers from Ward 46 or Manchester Royal Infirmary View source Failure of clinicians treating physical illness to undertake required capacity assessments View source Failure to learn from findings that a discharge or transfer should not take place 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
Charlotte Elizabeth Jacobs · 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
Charlotte Jacobs suffered an accidental fall at home on 11 October 2016, developed a deep tissue injury and sacral ulcer, later suffered a stroke, and died from heart failure and related disease on 31 October 2016. Concerns included the failure to assess her capacity to refuse treatment, fluids and nutrition, an inappropriate transfer to a psychiatric ward while she was physically unwell, continuing uncertainty about the appropriateness of such transfers, and incomplete transfer guidance.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of completed guidance and protocol for transfers from Manchester Royal Infirmary to Park House
Wider context from the report “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place.
2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out. This was not the role of the Psychiatric team.
3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation.
4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016).
In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of relevant staff to be aware of internal investigation findings
Wider context from the report “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place.
2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out. This was not the role of the Psychiatric team.
3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation .
4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016).
In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of further inappropriate discharges or transfers from Ward 46 or Manchester Royal Infirmary
Wider context from the report “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place.
2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out. This was not the role of the Psychiatric team.
3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation.
4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016).
In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally , leading to a risk of future deaths .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinicians treating physical illness to undertake required capacity assessments
Wider context from the report “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place.
2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out . This was not the role of the Psychiatric team .
3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation.
4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016).
In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from findings that a discharge or transfer should not take place
Wider context from the report “1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit , despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place .
2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out. This was not the role of the Psychiatric team.
3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation.
4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016).
In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths.
” Open source report
30 Sep 2019 Mary Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Delays in completing falls risk assessments View source Failure to manage risks from lost medical records View source Limited availability and low prioritisation of transport for frail elderly patient transfers View source Failure to clinically review fluid chart outcomes View source Failure to record or trace SALT referrals View source Clerking and risk assessment of frail elderly transfer patients out of hours View source Poor-quality nursing documentation of fluid charts View source Failure to refer frail patients to a dietician or nutritionist View source See 5 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 Jones · 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 Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing falls risk assessments
Wider context from the report “2. The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage risks from lost medical records
Wider context from the report “4. The documentation issue was exacerbated by the Trust IT merger having resulted in the loss of a number of key documents . It was unclear how the Trust were managing the risks around lost medical records where the IT merger was at the root of the issue;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability and low prioritisation of transport for frail elderly patient transfers
Wider context from the report “1. Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer . As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours. The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are a low priority and moved where needed ;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clinically review fluid chart outcomes
Wider context from the report “6. There was no evidence of clear clinical review of the outcome of the fluid charts .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record or trace SALT referrals
Wider context from the report “5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral ;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Clerking and risk assessment of frail elderly transfer patients out of hours
Wider context from the report “1. Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer. As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours . The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are a low priority and moved where needed;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor-quality nursing documentation of fluid charts
Wider context from the report “3. The documentation within the nursing notes, particularly the fluid charts was poor quality , making it difficult to understand what had happened in relation to the hydration of Mrs Jones;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer frail patients to a dietician or nutritionist
Wider context from the report “5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist . There was to have been a referral to SALT in February but no trace could be found of the referral;
” Open source report
14 Aug 2019 David John Smith · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2 Failure to transmit donor kidney CMV status to the renal transplant team View source Failure to communicate donor kidney CMV status to the transplant recipient for informed consent View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Smith · 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
David John Smith underwent a dual renal transplant involving kidneys from a CMV-positive donor, but the donor’s CMV status was not communicated to him and was incorrectly recorded as negative. He did not receive CMV prophylaxis, later developed CMV infection and ganciclovir resistance, deteriorated, and died on 5 July 2017. The principal concerns were the consent process and failures to communicate and accurately record the donor’s CMV status.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit donor kidney CMV status to the renal transplant team
Wider context from the report “1. The consent process – I found that the CMV status of the donor’s kidneys (listed as positive on the Electronic Offering System form) was never communicated to the Deceased for him to consider the risks of proceeding with the transplantation, and for him to provide informed consent.
2 Recording of the CMV status – When the plan for the deceased’s surgery was communicated to the Renal transplant team in an email, this did not include reference to the donor’s CMV status, nor did it attach the relevant EOS form . Consideration should be given to introducing a process in which the EOS form itself is sent onwards to the Renal transplant team to ensure important information such as the CMV status is not missed by 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate donor kidney CMV status to the transplant recipient for informed consent
Wider context from the report “1. The consent process – I found that the CMV status of the donor’s kidneys (listed as positive on the Electronic Offering System form) was never communicated to the Deceased for him to consider the risks of proceeding with the transplantation, and for him to provide informed consent.
2 Recording of the CMV status – When the plan for the deceased’s surgery was communicated to the Renal transplant team in an email, this did not include reference to the donor’s CMV status, nor did it attach the relevant EOS form. Consideration should be given to introducing a process in which the EOS form itself is sent onwards to the Renal transplant team to ensure important information such as the CMV status is not missed by the treating clinicians.
” 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 Strengthen transplant consent by specifically discussing and documenting donor-recipient CMV risks before transplantation.
Verbatim wording from the response “It was acknowledged that the consent process regarding the communication of donor risks, particularly CMV status, needed to be more robust and comprehensive so that all recipients are fully informed before transplantation.” Source location 2019-0271-Response-by-Manchester-University-NHS-Trust
Open published response
11 Mar 2019 Margaret Bernadette WILSON · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2 Failure to perform a guideline-compliant blood test for Endocarditis View source Prescribing antibiotics that mask Endocarditis 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
Margaret Bernadette WILSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Bernadette Wilson was admitted with swelling, pain and bruising, and was provisionally diagnosed with cellulitis and treated with antibiotics without prior blood tests. She later developed chest pain, was diagnosed with endocarditis, did not respond to treatment and died. The report identified concern that the absence of a blood test and the prescribing of antibiotics masked the endocarditis, and stated that earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform a guideline-compliant blood test for Endocarditis
Wider context from the report “1. A blood test should have been done, in compliance with national guidelines , which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease.
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Prescribing antibiotics that mask Endocarditis
Wider context from the report “1. A blood test should have been done, in compliance with national guidelines, which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease .
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
” Open source report
11 Mar 2019 Peter CARROLL · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2 Lack of leading physician sign-off for reports View source Delays in reporting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter CARROLL · 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
Peter CARROLL had a chronic ulcer that developed into malignancy, and died following peritonitis, a perforated caecal volvulus, and perianal squamous cell carcinoma, with coronary artery atheroma, pulmonary embolism and obesity also recorded. The report raised concerns about a six-month delay in biopsy reporting, the absence of leading physician sign-off, and failures in recording and labelling the biopsy, which may have prevented curable treatment from being offered.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of leading physician sign-off for reports
Wider context from the report “I am concerned that there is no leading physician signing off these reports in addition to processing by input on it systems thus reducing the effectiveness of the reporting.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting
Wider context from the report “I am concerned that a 6 month delay in reporting , on the evidence, meant that a curable treatment was not an option however if reported in a timely manner, would most likely have resulted in a favourable outcome.
” 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 Send pathology reports directly to the responsible clinician, including a printed copy marked “Urgent Report” when multidisciplinary discussion is delayed or unavailable.
Verbatim wording from the response “In the Department of Histopathology, measures have been instituted such that in the event of apparently unexpected or metastatic malignancy in a specimen from a site outside the pathologist’s area of expertise, that case is redirected to another pathologist who specialises in that field. All confirmed cancer cases are listed for discussion at relevant multidisciplinary team meetings (MDTs). In the case of delay or inability to discuss the appropriate MDT, pathologists/pathology administrative staff have been instructed to email the report directly to the responsible clinician. In addition, a printed report marked ‘Urgent Report’ will be sent to the responsible clinician.” Source location 2019-0162-Response-by-Manchester-University-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 Date-stamp incoming histology paper results, track them, require consultant review and sign-off, and monitor completion monthly.
Verbatim wording from the response “Within General Surgery, as part of the actions relating to this investigation, the team undertook a review of the administration processes in relation to histopathology paper results. The provision of paper results currently provides a backup assurance system to the electronic process. It was confirmed by the Administration Manager on 27 April 2017, that as part of this review into Mr Carroll’s case, all histology paper results are now date stamped upon arrival into the department” Source location 2019-0162-Response-by-Manchester-University-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 Operate a fully electronic, paperless test-result reporting system at Wythenshawe with electronic acknowledgement and clinician-review tracking.
Verbatim wording from the response “A further plan to improve communication of test results is currently being implemented at our Oxford Road site. At the Wythenshawe site of MFT, we introduced a fully electronic paperless system of reporting test results to requesting clinicians, which facilitates electronic results acknowledgement and allows tracking of clinician performance in reviewing results. We are currently introducing a similar system within the Chameleon EPR at Oxford Road site.” Source location 2019-0162-Response-by-Manchester-University-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 an electronic test-result reporting system within the Chameleon EPR at Oxford Road.
Verbatim wording from the response “A further plan to improve communication of test results is currently being implemented at our Oxford Road site. At the Wythenshawe site of MFT, we introduced a fully electronic paperless system of reporting test results to requesting clinicians, which facilitates electronic results acknowledgement and allows tracking of clinician performance in reviewing results. We are currently introducing a similar system within the Chameleon EPR at Oxford Road site.” Source location 2019-0162-Response-by-Manchester-University-NHS-Trust
Open published response
26 Feb 2019 Mr Geoffrey Jackson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to complete falls risk assessments in accordance with Trust requirements View source Absence of a requirement for structured narrative nursing records for each shift 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
Mr Geoffrey Jackson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Geoffrey Jackson died at Trafford General Hospital on 6 November 2018 following congestive cardiac failure and ischaemic heart disease, with left hip replacement and hospital-acquired pneumonia also recorded. He had an unwitnessed fall after required falls-risk assessments were not completed, although there was no evidence that the fall contributed to or materially hastened his death. Concerns included continuing omissions in falls-risk assessments and nursing records that lacked structured narrative accounts of patients’ conditions.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments in accordance with Trust requirements
Wider context from the report “1. Notwithstanding the actions which have been taken following the Trust’s investigation into the circumstances of Mr Jackson’s fall, a spot-check recently undertaken by the Matron on Ward 6 found 2 out of 32 patients had not had Risks of Falls Assessments completed in accordance with Trust requirements ;
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a requirement for structured narrative nursing records for each shift
Wider context from the report “2. A further matter of concern arose from the manner in which nursing records are made at Trafford General Hospital, with an emphasis on proforma care plans which simply require signing and dating by nurses, observation charts, and sheets upon which variance from the care plans can be recorded. It is a matter of concern that the absence of any requirement upon the nurse looking after a patient for a given shift to make a structured narrative record of what transpires over that period represents a missed opportunity to capture nuanced changes in a patient’s condition, and communicate these to others.
” Open source report
18 Oct 2018 Joseph James GRANTHAM · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to provide community health professionals with clear instructions for head-circumference monitoring and action View source Unavailability of paper clinical notes to clinicians at appointments View source Delays in sending post-outpatient clinical letters and requests for assessment View source Failure to maintain a complete composite child health record in the red book View source Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs View source Failure of information systems to make key clinical information available across trusts View source Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joseph James GRANTHAM · 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
Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community health professionals with clear instructions for head-circumference monitoring and action
Wider context from the report “4. Joseph had been diagnosed by the neurosurgeons at RMCH with neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation. A recognised complication is hydrocephalus. Identification of the onset of hydrocephalus is through measurement of head circumference. The inquest heard that when Joseph was discharged from St Mary's the neurosurgical team did not send written instructions to community health professionals explaining what was required and why it was required. The midwives measuring his head were unsure why they were measuring it or what to do with the information.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of paper clinical notes to clinicians at appointments
Wider context from the report “3. At ENT appointments and neurosurgery appointments at the RMCH, Joseph was seen without the paper notes because they had not been made available to the clinicians seeing Joseph.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in sending post-outpatient clinical letters and requests for assessment
Wider context from the report “2. Joseph was under the care of the paediatric neurosurgical team at the Royal Manchester Children's Hospital (RMCH). Letters from the neurosurgical team following out-patient appointments took 4 weeks to be sent out. As a result one letter to a paediatric anaesthetist asking for an examination was not typed until after the operation was due to take place. When his mother took him for review, she had to escalate the need for him to be seen by the paediatric anaesthetist who then deemed him not fit at that time for surgery.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a complete composite child health record in the red book
Wider context from the report “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs
Wider context from the report “5. Joseph's health needs relating to neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation and laryngomalacia were dealt with by the RMCH. His paediatric care was transferred without discussion by St Mary's back to the DGH. The inquest was told that there is no set protocol/ procedure between tertiary centres and DGH's for this situation, which can lead to differing practices.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of information systems to make key clinical information available across trusts
Wider context from the report “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician
Wider context from the report “1. After his birth Joseph was transferred to the neonatal unit at St Mary's due to the complexities of his health. Following his discharge, it took 6 weeks for the trust to send the discharge paperwork to the GP and the District General Hospital (DGH) to whom they were transferring his paediatric care. As a result, there was no clear understanding amongst health professionals as to the paediatrician with responsibility for his care . Letters were therefore copied into a mixture of paediatricians. The discharge letter to the DGH was addressed to a consultant who was in fact a registrar at the trust.
” Open source report
26 Sep 2018 Angela Mary Jackson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to provide accurate referral destination information for aortic aneurysm treatment View source Lack of approved documented pathways for referral and treatment of aortic aneurysms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Mary Jackson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate referral destination information for aortic aneurysm treatment
Wider context from the report “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital.
iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of approved documented pathways for referral and treatment of aortic aneurysms
Wider context from the report “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital.
iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England , although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem , which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce three regional referral pathways covering Cheshire and Merseyside, Wythenshawe and MRI, and Lancashire including Blackpool.
Verbatim wording from the response “Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expediously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements.” Source location Angela-Jackson-Response-1
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 Publish and distribute the Liverpool Acute Network for Thoracic Aortic Services pathway across the region and on the Trust website.
Verbatim wording from the response “A pathway was agreed between LiVES and LHCH and published known as Liverpool Acute Network for Thoracic Aortic Services (LANTAS), (Appendix 1). This was distributed around the region and placed on the LHCH Website.” Source location Angela-Jackson-Response-1
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 Confirm vascular clinicians’ awareness of the Lancashire and South Cumbria pathway and algorithm through clinical meetings and individual discussions.
Verbatim wording from the response “• Confirming awareness of the pathway and algorithm in doctors working within our vascular service at Lancashire Teaching Hospitals both through presentation at clinical meetings and individual discussions.” Source location Angela-Jackson-Response-1
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 Finalise and obtain approval for the Lancashire and South Cumbria pathway for managing aortic aneurysms.
Verbatim wording from the response “Prior to the inquest of Mrs Jackson, work had already begun within our organisation on producing a pathway for the Lancashire and South Cumbria Vascular Network. It is clear that this work needed to be extended to include the whole of the North West region incorporating all the specialist cardiothoracic centres and referring hospitals.” Source location Angela-Jackson-Response-1
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 consulting with Liverpool Heart and Chest Hospital and modifying Manchester’s referral guidance in line with wider cardiothoracic strategy and service specifications.
Verbatim wording from the response “Mr Bilal has consulted directly with colleagues at LHCH in respect of this written guidance; Mr Manoj Kuduvalli, Consultant Surgeon and Associate Medical Director for Surgery and Mr Mark Field, Aortic Lead, specifically considering alignment with the pathway provided by Mr Field on behalf of LHCH. Our Trust's guidance is agreed in principle by LHCH and is subject to ongoing consultation, discussions and modifications in line with wider cardiothoracic strategy and service specifications.” Source location Angela-Jackson-Response-1
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 Share the Lancashire and South Cumbria pathway and clinical algorithm with Medical Directors and Emergency Departments across the vascular network.
Verbatim wording from the response “• Sharing both the pathway and clinical algorithm with all Medical Directors and Emergency Departments across the Lancashire and South Cumbria Vascular Network.” Source location Angela-Jackson-Response-1
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 formally agreed written guidance for Greater Manchester acute aortic syndrome referrals and distribute it to covered hospitals and healthcare professionals.
Verbatim wording from the response “The concerns are acknowledged in their entirety by Manchester University NHS Foundation Trust. Steps have been taken in order to create and work towards implementing formalised written guidance on the referral system to the Trust for treatment of patients with aortic aneurysms and other conditions. The pathway has now been formally agreed at the Trust” Source location Angela-Jackson-Response-1
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 Publish the Manchester and Lancashire referral pathway documents and distribute the pathways to emergency departments.
Verbatim wording from the response “Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expediously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements.” Source location Angela-Jackson-Response-1
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 Formal organisation of thoracoabdominal aortic services and pathways will be addressed by NHS England’s national service specification.
Verbatim wording from the response “National Aortic Service Specification will eventually provide statutory requirements to organise service within the North West of England.” Source location Angela-Jackson-Response-1
Open published response
18 Jul 2018 Mohamed Rahman · Prevention of Future Deaths report Manchester (West)
View report summary
Concerns raised 6 Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time View source Lack of clinical guidance documents and procedures for unequivocal confirmation of fetal demise View source Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents View source Diminishing of scans for confirmation of fetal death View source Failure to formally record the exact time of cessation of fetal heart activity View source Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mohamed Rahman · 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
Baby Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance documents and procedures for unequivocal confirmation of fetal demise
Wider context from the report “3. Without intending to be prescriptive, it is the opinion that other Departments nationally aware of the tragic sequence of events which took place in Greater Manchester and should consider the implementation of clinical guidance documents and procedures to facilitate unequivocal confirmation of fetal demise .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents
Wider context from the report “4. Consideration should also be given to the desirability of a leaflet for parents which fully explains the feticide process using appropriately sensitive and lay terminology .
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Diminishing of scans for confirmation of fetal death
Wider context from the report “1. Mother in particular but also the experienced professionals involved were wholly unprepared for what they witnessed and the feelings of birth when “stunned”, “shocked” and “distressed” were amongst the epithets given in evidence to describe their experience with the birth. The Neonatal team were not present and would not have expected to be present and had to be called urgently to review what had occurred. However well-intentioned - the attempt to reduce the time that a patient waits for the Department of Fetal Medicine scan is time performed by diminishing the scan for confirmation of fetal death contributed to this unintended outcome after termination of the pregnancy.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record the exact time of cessation of fetal heart activity
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” Open source report
16 Jul 2018 Sheila Winifred Ridgway · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments 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
Sheila Winifred Ridgway · 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
Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Wider context from the report “1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously
” Open source report
16 Jan 2018 Edwin Hooper · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to ensure guideline-compliant CT scanning for patients with head injuries, especially those taking anti-coagulant medication, during on-site CT scanner service issues View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edwin Hooper · 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
Edwin Hooper was admitted with multiple serious medical conditions, including decompensated heart failure, kidney disease, sepsis and peripheral vascular disease. After a fall while receiving anticoagulant treatment, he sustained a traumatic intracranial bleed and progressively deteriorated before receiving palliative care and dying on 15 November 2016. The principal concern was whether patients with head injuries who are taking anticoagulants undergo CT scanning in accordance with NICE guidelines, particularly when there are on-site CT scanner service issues.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure guideline-compliant CT scanning for patients with head injuries, especially those taking anti-coagulant medication, during on-site CT scanner service issues
Wider context from the report “Please can you confirm what measures have been put in place to ensure patients with head injuries, especially those taking anti-coagulant medication, undergo CT scanning in accordance with NICE guidelines , particularly where there are service issues with CT scanners on site .
” 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 Provide training on NICE guidelines for hospital-acquired head injuries and require all new starters to complete it during Trust induction.
Verbatim wording from the response “Training on NICE guidelines for the management of hospital acquired head injuries has been undertaken, and is sustained with all new starters having to complete this on induction to the Trust.” Source location 2018-0016-Response-by-Manchester-University-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 Implement a CT scanner downtime escalation and dissemination process, supported by senior managers on call, out-of-hours protocol reminders, and posters in relevant clinical areas.
Verbatim wording from the response “In summary the measures put in place are a robust escalation and dissemination plan for any occurrences of CT scanner downtime. This is backed up with senior managers on call and the out of hours team being sent and reminded on the CT scanner downtime protocol (embedded in the action plan). A poster has also been designed and displayed in all relevant clinical areas, which describes the process clearly.” Source location 2018-0016-Response-by-Manchester-University-NHS-Trust
Open published response
Concerns raised 5 Failure of the system for audit of controlled-drug processes View source Failure of the system for documentation of controlled drugs View source Lack of escalation for admission of patients requiring continued observation or review View source Failure of high-level investigations to identify lessons View source Failure of the system for administration of controlled drugs 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
Stephen George Coulson · 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
Stephen George Coulson was discharged from Manchester Royal Infirmary after an increased Fentanyl patch was applied, with no record that the previous patch had been removed and despite confusion and agitation requiring further observation under hospital policy. He was found in cardiac arrest at home in the early hours of 1 January 2016 and died in intensive care later that day. The principal concerns were controlled-drug administration and documentation, failure to escalate the need for observation and review before discharge, and the Trust’s investigation failing to identify lessons.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for audit of controlled-drug processes
Wider context from the report “1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for documentation of controlled drugs
Wider context from the report “1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation for admission of patients requiring continued observation or review
Wider context from the report “2) Observation policy – the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of high-level investigations to identify lessons
Wider context from the report “3) High Level Investigation – the witness did not accept that any lessons could be learnt from the investigation surrounding the death 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for administration of controlled drugs
Wider context from the report “1) Controlled drugs – the system in place for the administration , documentation and audit of processes associated with the use of controlled drugs
” Open source report
Concerns raised 3 Failure to share learning from events with the new Trust View source Failure to access and consider appropriate records and previous relevant investigation and assessment results View source Failure to check emergency department patients for recent relevant presentations or admissions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr John Griffiths · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr John Griffiths had a history including ischaemic heart disease and presented with worsening shortness of breath and other symptoms before suffering a cardiac arrest at home and dying in hospital on 8 April 2016. The substantive concerns included failures to complete and process a cardiology referral, inadequate review of previous emergency-department records and investigations, and the absence of a system to identify relevant recent attendances or admissions.
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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share learning from events with the new Trust
Wider context from the report “3. The learning from these events needs to be shared with the new 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to access and consider appropriate records and previous relevant investigation and assessment results
Wider context from the report “2. If so, then appropriate records are accessed and considered including the results of previous relevant investigations and assessments . If a completely electronic patient record is introduced then this gives the opportunity for that to be achieved easily. Unless and until that occurs other checking processes need to be considered.
” 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 Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check emergency department patients for recent relevant presentations or admissions
Wider context from the report “1. UHSM did not appear to have a system or process that when patients attend the emergency department is it checked whether or not they have had any recent relevant presentations or admissions .
” 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 Use emergency-department alerts to identify recent attendances and prompt clinicians to review relevant electronic records.
Verbatim wording from the response “The ED system puts an alert on the front of the attending patient’s card when the patient’s details are entered into the system, which identifies how many previous attendances the patient has had in the last 2 years. An alert runs across the top of the electronic record as a prompt for the clinician to refer back to previous attendances if required. When Mr Griffiths attended on the 28 March 2017, the system successfully identified that he had attended once in the last 3 months and twice in the last 2 years. The Emergency Department will attempt to take a history from the patient and collate a historical history from those in attendance with them. The decision to refer back to the earlier admission on the electronic record is an individual decision and the alert is a prompt within the system to ensure the clinician is aware of previous attendances.” Source location 2017-0222-Response-by-UHSM
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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 Introduce the Electronic Patient Record System to enhance identification of patients’ relevant clinical histories in the emergency department.
Verbatim wording from the response “As described by ████████ within her evidence the systems in place to identify a patient’s relevant clinical history when presenting at the Emergency Department will be enhanced by the introduction of” Source location 2017-0222-Response-by-UHSM
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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 Share the coroner’s report and this response with the board of the new Trust.
Verbatim wording from the response “I can confirm that the Trust will share your report and this response with the board of the new Trust.” Source location 2017-0222-Response-by-UHSM
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Addressed to Central Manchester University Hospitals NHS Foundation Trust, now represented here by Manchester University NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations