Concerns raised 9 Insufficient senior nursing staff in leadership roles View source Failure to complete required neurological or general observations View source Insufficient staffing levels or staff competence for safe care View source Failure to ensure completion or handover and documentation of outstanding A & E investigations View source Failure to accurately record and calculate neurological or general observations View source Failure to escalate neurological or general observations appropriately View source Lack of a clear handover and review process for transfer to AMU View source Failure to assess mental capacity during admission and transfer View source Failure to progress outstanding basic investigations and assessments View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · 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
A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.
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 Insufficient senior nursing staff in leadership roles
Wider context from the report “6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation.
” 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 complete required neurological or general observations
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken , accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner , accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” 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 Insufficient staffing levels or staff competence for safe care
Wider context from the report “6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation.
” 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 completion or handover and documentation of outstanding A & E investigations
Wider context from the report “2. Ensuring all investigations/assessments are completed before a patient leaves A & E and ensuring an appropriate handover. It is appreciated that it will not be possible for all investigations and tests to be performed before a patient leaves the A & E department but if that is the case then the receiving ward should be informed and there should be a clear documented audit trail so it is clear what is outstanding .
” 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 accurately record and calculate neurological or general observations
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” 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 neurological or general observations appropriately
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated . This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” 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 handover and review process for transfer to AMU
Wider context from the report “3. Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU . It would seem sensible that a Senior Nurse/Sister be informed and can then ensure appropriate care is given.
” 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 assess mental capacity during admission and transfer
Wider context from the report “1. Mental Capacity. There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU .
” 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 progress outstanding basic investigations and assessments
Wider context from the report “4. Ensuring investigations are progressed as appropriate. There was no progression of necessary basic assessments/tests which remained outstanding . For example, a chest X-ray.
” Open source report
Concerns raised 4 Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission View source Failure to consider DoLS authorisation in the community View source Failure to undertake formal mental capacity assessments in the community View source Failure to formally assess and recognise mental capacity on hospital admission View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie Johnson · 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
Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or obtain up-to-date mental health and care-plan information on hospital admission
Wider context from the report “3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital , but nor did the hospital check or request information from those looking after him in the community . The concern is that in this case, the deceased’s death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital.
” 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 consider DoLS authorisation in the community
Wider context from the report “1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken .
” 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 formal mental capacity assessments in the community
Wider context from the report “1. Although it is appreciated that the events in question occurred later in 2014 following the Cheshire West case, it is a matter of concern that in the community, no formal mental capacity assessment was undertaken and no consideration of a DoLS authorisation was undertaken.
” 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 assess and recognise mental capacity on hospital admission
Wider context from the report “2. Consequently, upon his admission to hospital, it was not recognised that he lacked mental capacity . There was no formal assessment and he was treated as an ordinary patient .
” 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 Mandate level 3 Adult Safeguarding training for all registered nurses, covering DoLS and mental capacity.
Verbatim wording from the response “In addition we also mandate within the Trust that all registered nurses complete level 3 Adult Safeguarding training, which is the most advanced safeguarding training we offer clinicians; DoLS and mental capacity is covered within the body of this training. The safeguarding team also offer bespoke sessions to areas who require further support or detail regarding the completion of DoLS.” Source location MORRISON-Leslie-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the coroner’s concerns at the Trust Clinical Effectiveness Committee to consider how to improve consideration of mental capacity assessments and DoLS authorisations.
Verbatim wording from the response “Moving forward and in order to improve the consideration given to mental capacity assessments and DoLS authorisations, your letter will be discussed at the Trust Clinical Effectiveness Committee to note your concerns and consider how this should be addressed. Any further action will then be monitored via this committee and allocated to the relevant leads.” Source location MORRISON-Leslie-Response
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 Trustwide policy or pathway for proactively gathering complex and vulnerable patients’ up-to-date information from external health providers.
Verbatim wording from the response “Currently as a Trust we do not have a formal policy in place for the sharing of up to date information for patients who are vulnerable or have complex conditions. Whilst staff will informally liaise with care agencies or primary care, this is ad hoc and not an embedded process therefore relies on the staff providing care to a patient to proactively consider the information that may be held elsewhere. There are exceptions to this however, such as patients with learning disabilities, where there is a formal process in place through the use of their LD passport; however this is not consistent across other patient groups. As a result of the findings of this case we will implement a Trustwide initiative regarding the development of a policy or pathway for complex and vulnerable patients which will include proactively gathering information from health providers outside of the Trust.” Source location MORRISON-Leslie-Response
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 Arrange external training sessions on mental capacity and DoLS with the Trust’s solicitor partnership firm.
Verbatim wording from the response “With regards to staff training around mental capacity and DoLS, I can confirm that we have monthly DoLS training sessions in place regarding awareness of the process and the completion of DoLS and mental capacity assessments. In addition there have also been sessions arranged with our Solicitor partnership firm for external training sessions to be held.” Source location MORRISON-Leslie-Response
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 implementing frailty and delirium screening tools, including a unified tool across Trafford and the central site.
Verbatim wording from the response “The Trust is in the process of implementing a transformation project regarding a delirium tool and a frailty flag to help identify those patients who may have reduced capacity. The Trust are working with Patientrack, our partners for the electronic Early Warning Score system, to embed a frailty screen in patients aged over 75 which would then identify patients requiring a comprehensive geriatric assessment. The next stage would be to embed a delirium screen into Patientrack. This work continues to progress and currently a pilot of frailty screening, CGA and delirium screening is taking place at our Trafford site, from which the initial feedback is positive. This will then be developed to produce a unified tool across Trafford and central site and support the care provided to our vulnerable, frail and elderly population.” Source location MORRISON-Leslie-Response
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 Consider including safeguarding, particularly DoLS and mental capacity, at quarterly Audit and Clinical Effectiveness Days and make implementation plans.
Verbatim wording from the response “We are also considering the inclusion of safeguarding at each of our quarterly Audit and Clinical Effectiveness Days, focusing in particular on DoLS and mental capacity. This will be discussed further and plans for implementation made.” Source location MORRISON-Leslie-Response
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 monthly DoLS training on the process and completion of DoLS and mental capacity assessments.
Verbatim wording from the response “With regards to staff training around mental capacity and DoLS, I can confirm that we have monthly DoLS training sessions in place regarding awareness of the process and the completion of DoLS and mental capacity assessments. In addition there have also been sessions arranged with our Solicitor partnership firm for external training sessions to be held.” Source location MORRISON-Leslie-Response
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 bespoke safeguarding sessions to areas needing additional support with completing DoLS and mental capacity assessments.
Verbatim wording from the response “In addition we also mandate within the Trust that all registered nurses complete level 3 Adult Safeguarding training, which is the most advanced safeguarding training we offer clinicians; DoLS and mental capacity is covered within the body of this training. The safeguarding team also offer bespoke sessions to areas who require further support or detail regarding the completion of DoLS.” Source location MORRISON-Leslie-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A finding of lacking mental capacity alone does not require a DoLS authorisation; the decision depends on specific care arrangements and possible liberty deprivation.
Verbatim wording from the response “As I am sure you are aware, mental capacity (as defined in the Mental Capacity Act 2005) is decision specific and a finding of ‘lack of mental capacity’ alone is not sufficient to justify a DOLS emergency or standard authorisation. This requires a finding of lack of mental capacity to make decisions about location and manner of care and judgement about the specific manner of care in place at the material time. With regards to a DOLS emergency or standard authorisation, this is about the manner in which a person is cared for not about the care provided per se. It is therefore a matter of judgement for the responsible person with overall responsibility for the environment in which a person is cared for, to decide whether there has been or is a risk of an Article 5 breach in which case authorisation can be sought.” Source location MORRISON-Leslie-Response
Open published response
Concerns raised 2 Lack of adequate medical oversight of first post-operative reviews View source Failure to ensure adequate medical oversight of nurse-led patient discharges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patrick Curran · 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
Patrick Curran was diagnosed with lung cancer, underwent surgery, and was discharged with a chest drain. He was subsequently reviewed at nurse-led appointments without seeing a doctor, and at a four-week post-discharge review was frail, losing weight and struggling to recover. He was admitted with a pneumonia that had been developing for weeks and died in the early hours of 22 February 2016. The principal concerns were the lack of adequate medical oversight of postoperative reviews and the discharge of patients by nursing staff without adequate medical overview.
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 adequate medical oversight of first post-operative reviews
Wider context from the report “It is highly likely that Mr Curran had a pneumonia on 12th February, hence his presentation as described by the Specialist Sister. It is possible that the pneumonia was present at the chest drain reviews.
It causes me great concern that a patient who must have been presenting as unwell and not as expected at a 4 weeks post-operative was not only not seen by a doctor , but was discharged without the Consultant in charge’s knowledge.
I also have concerns about the fact that over 3 appointments at a ‘nurse-led’ clinic despite there being issues with the chest drain Mr Curran was not once reviewed by a doctor .
████████ told me that he spoke with the Specialist Sister involved but I am not satisfied that this provides me with adequate assurance that,
a) first post-operative reviews and discharges of patients without a doctor seeing
that patient is not a common and accepted practice, in the main because in many of the answers given to me on this element of the care provided to Mr Curran ████████ was keen to enlighten me as to how experienced this particular Specialist Sister was.
b) and in the circumstances this will not happen again.
I had no evidence as to whether or not had ████████ seen Mr Curran the outcome would have been different. It seems to me that there was at least the possibility that the outcome would have been different.
1. That Wythenshawe Hospital have adopted or condoned a practice whereby first post-operative reviews are conducted by nursing staff (of whatever specialist level of training) without any or any adequate medical overview .
2. That Wythenshawe Hospital have adopted or condoned a practice whereby patients can be, and, discharged from care at first post-operative review, or indeed any review, by nursing staff (of whatever specialist level of training) without any or any adequate medical overview.
” 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 adequate medical oversight of nurse-led patient discharges
Wider context from the report “It is highly likely that Mr Curran had a pneumonia on 12th February, hence his presentation as described by the Specialist Sister. It is possible that the pneumonia was present at the chest drain reviews.
It causes me great concern that a patient who must have been presenting as unwell and not as expected at a 4 weeks post-operative was not only not seen by a doctor, but was discharged without the Consultant in charge’s knowledge .
I also have concerns about the fact that over 3 appointments at a ‘nurse-led’ clinic despite there being issues with the chest drain Mr Curran was not once reviewed by a doctor.
████████ told me that he spoke with the Specialist Sister involved but I am not satisfied that this provides me with adequate assurance that,
a) first post-operative reviews and discharges of patients without a doctor seeing
that patient is not a common and accepted practice, in the main because in many of the answers given to me on this element of the care provided to Mr Curran ████████ was keen to enlighten me as to how experienced this particular Specialist Sister was.
b) and in the circumstances this will not happen again.
I had no evidence as to whether or not had ████████ seen Mr Curran the outcome would have been different. It seems to me that there was at least the possibility that the outcome would have been different.
1. That Wythenshawe Hospital have adopted or condoned a practice whereby first post-operative reviews are conducted by nursing staff (of whatever specialist level of training) without any or any adequate medical overview.
2. That Wythenshawe Hospital have adopted or condoned a practice whereby patients can be, and, discharged from care at first post-operative review, or indeed any review, by nursing staff (of whatever specialist level of training) without any or any adequate medical overview .
” 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 post-operative clinics by having a consultant present alongside nurse-led reviews, including the first post-operative review.
Verbatim wording from the response “Notwithstanding this, we would like to reassure you that there was medical oversight at these clinics. When Mr Curran was seen at clinic in February 2016, the clinic would be nurse-led with the consultant surgeon available by telephone. We have strengthened this and now our post-operative clinics are led by nurses but with a consultant present in the same clinic.” Source location 2016-0258-Response-by-University-Hospital-of-South-Manchester
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 at the February 2016 review was considered appropriate because imaging was compatible with normal post-operative findings and histology remained pending.
Verbatim wording from the response “Mr Curran’s x-ray taken on 12 February 2016 did not reveal a chest infection or pneumonia. A plan was made, on the basis that Mr Curran’s histology was not currently available, for him to receive his histology at a separate time by way of follow up from ████████. The decision regarding chemotherapy was not made until the histology was available. It was therefore, in our view, entirely appropriate, based on his presentation on 12 February 2016 to discharge him albeit without his histology results which were to be given at a later appointment. ████████ did not feel the need to review Mr Curran but had he been asked to review Mr Curran, it is his view that based on his x-ray and the description of Mr Curran’s presentation he would not have admitted him. The x-ray from the 12 February 2016 was compatible with post-operative findings.” Source location 2016-0258-Response-by-University-Hospital-of-South-Manchester
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 Nurse-led post-operative clinics are considered adequate because trained nurses conduct reviews with consultant support and strengthened same-clinic consultant presence.
Verbatim wording from the response “Thank you for making the Trust aware of your concerns. In line with a national move towards nurse-led clinics the expertise and training of our nursing staff renders them very capable of conducting post-operative clinics in the cardiothoracic unit. Thoracic surgery patients are seen in the outpatient clinic for their follow ups by any member of the team and this could be the Consultant, Registrar, SHO or a specialist nurse who has many years of thoracic surgery experience. All clinics are supported by Consultant cover as required. If there are concerns with a patient they are always discussed with the Consultant or if there are any concerns with an x-ray, Radiology are asked to report these.” Source location 2016-0258-Response-by-University-Hospital-of-South-Manchester
Open published response
Concerns raised 3 Failure to assess the reliability of negative allergy histories from patients or accompanying persons View source Failure to preserve documented penicillin and aspirin allergy information on the inpatient prescription and administration record View source Failure to prevent prescribing and administration of penicillin-based antibiotics despite a recorded penicillin allergy 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
Peter Arthur Rowe · 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 Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.
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 assess the reliability of negative allergy histories from patients or accompanying persons
Wider context from the report “3. On the evidence heard at the Inquest Mr Rowe suffered from very poor memory following his stroke in 1993. In the premises I am concerned that negative answers to questions regarding any allergies stated to have been put to both Mr Rowe and ████████ were accepted at face value when,
a) Mr Rowe suffered from significant memory loss and decreased cognitive function , and
b) When ████████ would not necessarily have known of her husband’s allergy (and indeed did not) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve documented penicillin and aspirin allergy information on the inpatient prescription and administration record
Wider context from the report “2. The fact of the GPs referral letter stating an allergy to both penicillin and aspirin appears to have been transferred on to the Adult Inpatient Prescription and Administration record and then deleted , albeit it is not clear by whom and when.
” 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 prevent prescribing and administration of penicillin-based antibiotics despite a recorded penicillin allergy
Wider context from the report “1. That despite the GPs referral letter stating an allergy to penicillin, a penicillin based prophylactic antibiotic was prescribed and administered .
” Open source report
28 Apr 2016 Patrick McGagh · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to ensure prescribed antibiotics are supplied to patients on discharge View source Failure to communicate prescribed antibiotic instructions to care staff and the GP View source Failure to provide discharge information to the GP View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patrick McGagh · 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
Patrick McGagh died at his care home from natural causes; the medical cause of death was recorded as pneumonia, coronary artery atheroma and hypertensive heart disease. After discharge from hospital, no discharge information or prescribed antibiotics were provided to his GP or care staff, who were therefore unaware that he should have been taking them.
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 prescribed antibiotics are supplied to patients on discharge
Wider context from the report “On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor . Neither the care staff nor the GP was aware that he should have been taking these antibiotics.
” 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 prescribed antibiotic instructions to care staff and the GP
Wider context from the report “On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics .
” 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 discharge information to the GP
Wider context from the report “On the 5th November 2015 he was seen by his GP and he had just been discharged from Wythenshawe Hospital three days previously. No discharge letter or note had been provided to the GP nor had the patient been sent home with any of the antibiotics which had been prescribed to him by the hospital doctor. Neither the care staff nor the GP was aware that he should have been taking these antibiotics.
” 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 Remind emergency-department and clinical-decisions-unit staff to supply prescribed medications, communicate instructions to patients and carers, and document this in clinical records.
Verbatim wording from the response “It is documented within the clinical records that Mr McGagh’s carer was advised regarding using a scrotal support and also to monitor for any skin changes and for Mr McGagh to return to hospital urgently if any concerns or his symptoms deteriorate. It is not explicit within the records if the carer in attendance was advised regarding the antibiotics. We agree apologise for this omission, all clinical ED staff have been reminded of the importance of supplying verbal and written instruction as required and this interaction must then be documented in the clinical health records.” Source location 2016-0171-Response-by-University-Hospital-of-South-Manchester
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a retrospective audit of emergency-department discharge prescriptions and evidence that medications were dispensed and communicated in line with policy.
Verbatim wording from the response “Actions taken:” Source location 2016-0171-Response-by-University-Hospital-of-South-Manchester
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 Commence a regular emergency-department audit programme monitoring compliance with medication-supply and documentation policy.
Verbatim wording from the response “To support ongoing improvements a regular audit program within the ED to monitor compliance with the policy and documentation has been commenced. Any individual staff identified that are not adhering to the required processes will be managed accordingly.” Source location 2016-0171-Response-by-University-Hospital-of-South-Manchester
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 Emergency Department attendance notifications are not sent because local GPs agreed they were unnecessary; formal discharge letters follow inpatient stays only.
Verbatim wording from the response “The Trust does not send notification of attendance to the Emergency Department. This decision was made following consultation with local GP’s, where it was agreed that the ED would no longer issue a notification of attendance on discharge from the ED. Formal discharge letters are produced only following an in-patient stay.” Source location 2016-0171-Response-by-University-Hospital-of-South-Manchester
Open published response
Concerns raised 4 Incomplete history taking View source Failure to recognise and act on symptoms of possible anaphylactic shock View source Failure to obtain basic blood tests for infection or sepsis analysis View source Failure to communicate clinical history appropriately to treating doctors View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Norma Edwina Holden · 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 Edwina Holden presented to the Accident and Emergency Department with abdominal pain, facial and mouth swelling, a swollen tongue and muffled speech, and was later found to have died from septic shock. Concerns included incomplete history-taking and communication to treating doctors, failure to recognise and act on apparent symptoms such as possible anaphylactic shock, lack of appropriate tests, and failure to obtain basic blood tests for infection or sepsis.
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 Incomplete history taking
Wider context from the report “During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled.
████████ was unaware of the symptoms of swollen tongue and facial swelling.
I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted.
In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics.
” 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 recognise and act on symptoms of possible anaphylactic shock
Wider context from the report “During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled.
████████ was unaware of the symptoms of swollen tongue and facial swelling.
I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock , and appropriate tests conducted.
In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics.
” 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 basic blood tests for infection or sepsis analysis
Wider context from the report “During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled.
████████ was unaware of the symptoms of swollen tongue and facial swelling.
I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted.
In addition, basic blood tests were not obtained for analysis of any infection/sepsis , to enable appropriate targeting of antibiotics.
” 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 clinical history appropriately to treating doctors
Wider context from the report “During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled.
████████ was unaware of the symptoms of swollen tongue and facial swelling.
I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted.
In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics.
” Open source report
Concerns raised 2 Unavailability of urgent endoscopy at Trafford View source Failure to provide urgent endoscopy at the Manchester Royal Infirmary 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
Leslie Alan Summerfield · 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
Leslie Alan Summerfield was admitted to Trafford General Hospital in late June 2015 and suffered a subdural haematoma following relatively minor trauma during the last two weeks of his life; the pathologist concluded that the injury occurred while he was in hospital. Concerns were raised about the lack of urgent endoscopy at Trafford, the ambulance transfers to and from Manchester Royal Infirmary, and the potential for this to have caused unnecessary discomfort or weakened him.
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 urgent endoscopy at Trafford
Wider context from the report “The Consultant Physician giving evidence to me indicated that she felt he needed an urgent endoscopy and that such a facility used to be available on site at Trafford, and indeed the equipment and staff members are still there, but only for use as a planned facility, not as an urgent request . If this is the case, is it safe to continue to treat patients with this type of illness at a hospital where the Management has withdrawn this essential service ? In fact he was transported by ambulance to and from the Manchester Royal Infirmary despite the fact that he was a very sick man. The urgent endoscopy was not done at the MRI and he was sent back to Trafford for a “planned” endoscopy to take place.
At the very least this caused him considerable unnecessary discomfort, and at worst may have weakened him such as to aggravate his pre-existing co-morbidities.
” 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 urgent endoscopy at the Manchester Royal Infirmary
Wider context from the report “The Consultant Physician giving evidence to me indicated that she felt he needed an urgent endoscopy and that such a facility used to be available on site at Trafford, and indeed the equipment and staff members are still there, but only for use as a planned facility, not as an urgent request. If this is the case, is it safe to continue to treat patients with this type of illness at a hospital where the Management has withdrawn this essential service? In fact he was transported by ambulance to and from the Manchester Royal Infirmary despite the fact that he was a very sick man. The urgent endoscopy was not done at the MRI and he was sent back to Trafford for a “planned” endoscopy to take place.
At the very least this caused him considerable unnecessary discomfort, and at worst may have weakened him such as to aggravate his pre-existing co-morbidities.
” Open source report
Concerns raised 11 Failure of biochemistry laboratories to escalate blood test results View source Failure to provide radiologists with current blood results before scanning View source Insufficient critical care nurse capacity for immediate High Dependency Unit transfer View source Failure to manage metformin medication before CT scanning View source Failure to record who requested further blood tests View source Failure of treating medical staff to recognise serious medical conditions View source Failure to escalate blood test results View source Failure to carry out required medical treatment View source Failure of GP practices to know the timing of referred CT scans View source Delays in recognising serious blood-test results View source Failure to admit patients as emergencies despite serious blood-test results View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bryan Herbert Whitby · 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
Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.
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 biochemistry laboratories to escalate blood test results
Wider context from the report “4. The results of the blood tests on the 6th May should have resulted in urgent discussion with the deceased’s GP or the deceased himself. There was no escalation of these results by the biochemistry laboratory .
” 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 radiologists with current blood results before scanning
Wider context from the report “2. Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication. The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago .
” 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 Insufficient critical care nurse capacity for immediate High Dependency Unit transfer
Wider context from the report “7. The Inquest also heard evidence that Mr Whitby required transfer to the High Dependency Unit but this could not take place immediately as two critical care nurses were required and one had been sent to Manchester Royal Infirmary as was the practice if there were no patients in the HDU at the start of their shift.
” 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 metformin medication before CT scanning
Wider context from the report “2. Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication . The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago.
” 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 who requested further blood tests
Wider context from the report “3. There is no record of who requested further blood tests on the 6th May .
” 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 treating medical staff to recognise serious medical conditions
Wider context from the report “6. When he was admitted into hospital there was a failure by the treating medical staff to recognise his serious medical condition and then a failure to carry out the required medical 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 Failure to escalate blood test results
Wider context from the report “2. Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication. The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago.
” 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 carry out required medical treatment
Wider context from the report “6. When he was admitted into hospital there was a failure by the treating medical staff to recognise his serious medical condition and then a failure to carry out the required medical 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 Failure of GP practices to know the timing of referred CT scans
Wider context from the report “1. The deceased had been unwell for some time and had a history of Chronic Kidney Disease Stage 3. He had been referred for a CT scan but the GP Practice were not aware of the date of the scan or that this would take place on the 3rd May .
” 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 recognising serious blood-test results
Wider context from the report “5. Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results . I had given evidence that training for junior members of staff on acute kidney injury has now been delivered.
” 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 admit patients as emergencies despite serious blood-test results
Wider context from the report “5. Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results. I had given evidence that training for junior members of staff on acute kidney injury has now been delivered.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and disseminate acute kidney injury guidelines through Acute Medical Unit displays and the locum doctor handbook.
Verbatim wording from the response “The Trust's AKI guidelines, which support the recognition of severity and the management of AKI in line with NICE guidance August 2013, have been fully implemented and are clearly displayed on the Information Board and in the Doctors' office on the AMU. The guidelines are also now included in the Handbook provided to Locum Doctors.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check for later renal-function results before administering intravenous contrast to patients with known chronic kidney disease.
Verbatim wording from the response “As a result of this incident, the Radiology Department have reviewed their practice in relation to the timing and assessment of renal function prior to intravenous contrast administration. Following this review they have implemented a process to check for any later results prior to giving contrast injections for CT scans as a routine protocol for all patients with known CKD.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain two critical care nurses on the Trafford site at all times for High Dependency Unit transfers and care.
Verbatim wording from the response “Since the date of the incident regarding the transfer of Mr Whitby to the High Dependency Unit, two Critical Care Nurses have been on site at Trafford at all times. The Critical Care Service has recently reviewed the use of Trafford's High Dependency Unit and is widening the scope for the type of patients who can be nursed there in the future. This means that not only will the Critical Care Nurses be based on the Trafford site – they will be based at all times on the High Dependency Unit.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lower the creatinine alert threshold to 400 µmol/L and telephone qualifying results on the same day.
Verbatim wording from the response “Mr Whitby's blood results were not escalated by the Chemical Pathology Laboratory on 06 May 2014 as the 500umol/L threshold followed in the Laboratory at that time for Creatinine had not been breached. Chemical Pathology have now lowered the telephoning limit for Creatinine results from 500umol/L to 400umol/L and these results are telephoned through on the same day.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver acute kidney injury recognition and management training for junior and other relevant staff.
Verbatim wording from the response “Despite blood results, Mr Whitby was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results. Training for junior members of staff on AKI has now been delivered.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the case and its lessons through staff debriefing, Medical Grand Round and divisional audit and clinical effectiveness presentations.
Verbatim wording from the response “Medical and nursing staff on the Acute Medical Unit attended a debriefing session to discuss the care and treatment of Mr Whitby and the lessons learned. His case was also presented to medical staff at a Medical Grand Round and was presented more widely at the Divisional Audit and Clinical Effectiveness (ACE) day on 17 October 2014. The case was presented by ████████ Consultant, who discussed the missed opportunities and the chain of events. The presentation of Mr Whitby's case was followed by a presentation by ████████ Consultant in Nephrology and Intensive Care Medicine, who explained to staff how the Trust is tackling AKI. ████████ explained how AKI was a safety priority for the Trust and also explained the role of the Renal team and of the AKI Specialist Nurses.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Trust-wide acute kidney injury alert system, with same-day telephone escalation for Stage 3 alerts and case-by-case review of Stage 1 and 2 alerts.
Verbatim wording from the response “Consultant Chemical Pathologist, ████████ and ████████, Chief Biomedical Scientist in Chemical Pathology, have confirmed that a review of the processes for urgently notifying GPs of abnormal test results has been undertaken. On 09 March 2015, the Biochemistry Department went live with an Acute Kidney Injury (AKI) alert system. In future all Stage 3 alerts will be telephoned as soon as possible on the same day. Stage 1 and 2 alerts will be reviewed on a case by case basis.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The recorded eGFR was within relevant guidance thresholds, so the contrast scan and Metformin use did not indicate concern.
Verbatim wording from the response “At this time, the eGFR result was 71 and there was no indication in the information the Radiology Department received that there was any concern over Mr Whitby's renal status. The Surgeon recorded on the referral form for the CT scan with contrast that Mr Whitby's eGFR was 71 and that he was taking Metformin for his Type II diabetes. These eGFR results did not cause concern as they were well within the Royal College of Radiologists and NICE guidance for giving contrast which is 50 for intravenous contrast and 60 for stopping Metformin.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Radiology need not routinely notify GPs of scan dates or results; the specialist communicates the complete investigation outcome afterward.
Verbatim wording from the response “The Directorate Manager for Radiology has advised that Radiology would not normally inform a GP of scan dates or send the results to them unless they were the referring Clinician. The scan was requested on 29 April 2014 by ████████ Surgical Registrar, in the lower gastrointestinal (GI) clinic.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
Concerns raised 6 Lack of a written protocol defining increased observations and required recording View source Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations View source Failure to assign clear responsibility for recording increased observations View source Failure to ensure nursing and clinical staff understand their record-keeping responsibilities View source Lack of written guidance for clinical review and care-plan changes in response to new risks View source Lack of periodic audits of record keeping in similar cases 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
Kimberley Lauren Lindfield · 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
Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.
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 written protocol defining increased observations and required recording
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist .
” 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 auditing of the appropriateness and timeliness of responses to mental health assessment presentations
Wider context from the report “1. I am told that all patients presenting with symptoms of mental illness/mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible whether that referral is from A& E or any ward. Pending that assessment, mental health staff can give advice by phone concerning the patients interim care and management. Both UHSM and MHSC provided evidence about a joint understanding and approach as well as a training and induction of staff. GMW may also be involved in such a case. That was to a very large extent the assurance I was provided after the death of Mr Dean. There were no plans or thoughts to audit whether or not in practice there was an appropriate and timely response to such presentations to ensure that the new system was actually working. In view of the history I am concerned that without such an auditing process failures of care may take place as identified 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 assign clear responsibility for recording increased observations
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done . I am concerned that at present such does not exist .
” 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 nursing and clinical staff understand their record-keeping responsibilities
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met.
” 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 written guidance for clinical review and care-plan changes in response to new risks
Wider context from the report “3. I am concerned that there is currently no written protocol or guidance where there is an appropriate clinical review and there should be a change in the care and management plan in response to new or changed circumstances or new risks .
” 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 periodic audits of record keeping in similar cases
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met .
” Open source report
Concerns raised 4 Unsafe retail display of button batteries accessible to small children View source Lack of lockable battery compartments in non-toy torches View source Lack of knowledge about managing incidents involving ingested button batteries View source Insufficient national awareness of the risks of ingested button batteries View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Eliza Bashir · 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
Eliza Bashir swallowed a button battery from a torch on 22 March 2013. Although the battery was removed and she remained well for almost a week, she collapsed on 30 March 2013 and died after resuscitation failed. Concerns included the lack of a lockable battery compartment because the torch was not classified as a toy, uncertainty among clinicians about managing such incidents, and the accessibility and sale of button batteries to young children.
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 Unsafe retail display of button batteries accessible to small children
Wider context from the report “4. Concern remains that such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to gain access to them whilst unobserved .
” 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 lockable battery compartments in non-toy torches
Wider context from the report “1. Evidence from the Trading Standards Officer confirmed that because the torch was not classified as a toy, it did not require a lockable battery compartment , notwithstanding compliance with safety regulations.
” 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 knowledge about managing incidents involving ingested button batteries
Wider context from the report “2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally.
” 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 Insufficient national awareness of the risks of ingested button batteries
Wider context from the report “2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally .
” Open source report
Concerns raised 1 Unavailability of midwives for timely attendance at planned home births View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Antonio Jerome Allen · 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
Antonio Jerome Allen was admitted to Trafford General Hospital in cardiac arrest on 26 June 2013 after being found unresponsive at home, and could not be revived. Concerns were raised that midwives could not be contacted for the planned home birth and arrived only after the delivery had occurred.
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 midwives for timely attendance at planned home births
Wider context from the report “It had been arranged that this was to be a home birth and the midwives based at Lostock Medical Centre were aware of this. His expected date of delivery was the 15th June but in fact he was born on the 17th June.
The mother and grandmother of Antonio tried on four separate occasions to call out a midwife to attend the birth but in fact the delivery had to be carried out by the grandmother and a neighbour. Two midwives eventually arrived, checked the baby and said all was well although he was a bit ‘puffy’ because it was a ‘quick birth’.
IF A HOME BIRTH IS BOOKED AND EXPECTED OR INDEED OVERDUE, IT SHOULD NOT BE THE CASE THAT THE MIDWIVES ARE NOT CONTACTABLE, NOR THAT THEY ARRIVE AFTER THE BIRTH HAS OCCURRED.
” 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 women with two telephone numbers for planned home-birth support.
Verbatim wording from the response “On being informed by Midwife ████████ of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning.” Source location 2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
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 Reconnect the faulty dedicated telephone line.
Verbatim wording from the response “On being informed by Midwife ████████ of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning.” Source location 2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
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 Establish a standard operating procedure for checking essential telephone lines function at the start of each shift.
Verbatim wording from the response “Following her return to the hospital Midwife ████████ alerted the radio telephone administration staff of the difficulties experienced by the family. On investigation it was identified that there had been a known fault on the telephone line earlier in the day but this had been resolved by the engineers. There is a process in place to ensure that the essential telephone lines are checked at the beginning of each shift; it was apparent that the administrator did not follow the process for checking the phone line at commencement of their shift so was unaware that the fault had reoccurred.” Source location 2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Open published response
Concerns raised 8 Unavailability of nursing notes, observation charts and pressure ulcer charts View source Inappropriate placement of patients on a complex discharge ward View source Failure to update falls risk and bed rails assessments in accordance with policy View source Lack of nursing staff training and confidence in administering prescribed oral morphine View source Delays in informing next of kin after a hospital fall View source Failure of timely coordination and availability for inter-hospital patient transfers View source Failure of patient-note transfer between paper-based and electronic hospital systems View source Failure of a TAB alarm to remain attached or activate when no longer offering protection View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
THOMAS PATRICK MAHER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.
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 nursing notes, observation charts and pressure ulcer charts
Wider context from the report “1. All the nursing notes, observation charts and pressure ulcer charts for the period 20th December 2013 to 29th January 2014 are missing , and despite a widespread search by the hospital, it has proved impossible to locate them . This had the effect of hampering the High Level Investigation and potentially the inquest itself.
” 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 Inappropriate placement of patients on a complex discharge ward
Wider context from the report “6. On the 5th February 2014 ████████ elderly care consultant, read Mr Maher’s notes and said that the complex discharge ward was not the appropriate place for Mr Maher to be and that he should be transferred to a medical or orthopaedic ward . Why was he on the inappropriate ward in the first 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 update falls risk and bed rails assessments in accordance with policy
Wider context from the report “2. On a number of occasions during his stay in the hospital, the falls risk assessment and the bed rails assessment were not updated per policy .
” 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 nursing staff training and confidence in administering prescribed oral morphine
Wider context from the report “5. On returning to the ward the doctors had prescribed oral morphine but the nursing staff were not trained/confident in giving this so the prescription had to be altered to oral morphine.
” 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 informing next of kin after a hospital fall
Wider context from the report “7. After he sustained the fall in hospital, there was a delay of almost four hours before his next of kin was informed .
” 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 timely coordination and availability for inter-hospital patient transfers
Wider context from the report “4. On or around the 3rd February, a discussion took place between the treating doctor at Trafford and an orthopaedic specialist at MRI, during which it was agreed that a bed was available at MRI and that Mr Maher would be transferred. The ambulance was ordered to transport him and Mr Maher was taken and placed in the vehicle. In fact it then transpired that there was no bed available so he had to be taken from the vehicle and returned to the ward at Trafford General .
In the course of his evidence to me, the consultant Physician stated “we have major problems getting patients transferred to MRI and other hospitals, we frequently have to wait 3 or 4 days for transfer of a patient who should have gone immediately ”. He then went on to state that in his opinion the ability to transfer patients between divisions of the same trust should be ‘second to none’ and in fact it is less than adequate .
” 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 patient-note transfer between paper-based and electronic hospital systems
Wider context from the report “8. There is an apparent major problem with regard to patient notes where those at MRI are ‘paper based’ whereas those at Trafford are electronic . I was told that it will be at least two years before this situation is reconciled. This is inherently dangerous in that the treating doctors may not have the up to date notes available to them . Both senior doctors who gave evidence to me described the system of transfer of notes between hospitals as “impossible” .
” 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 a TAB alarm to remain attached or activate when no longer offering protection
Wider context from the report “3. As a result of his perceived propensity to fall and to get out of bed, Mr Maher had a TAB alarm attached. It subsequently transpired that when he fell and broke his pelvis, this alarm had been removed and placed on his bed . If this were removed by a member of staff, then this would indicate a potentially negligent act; if removed by the patient then surely the alarm should activate to show that it is no longer offering protection .
” 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 Run the Health Records Improvement Programme to address patient-record management risks.
Verbatim wording from the response “The Trust acknowledges that the management of patient records is a significant risk. The risk is included on the Trust Risk Register and a Health Records Improvement Programme is underway to address the issues. As explained earlier, there is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 the Patientrack electronic observation and early-warning-score monitoring system across Trafford Hospital.
Verbatim wording from the response “In the future, the recording of observations will be electronic with the implementation of the Patientrack early warning score monitoring system. The implementation of this new system is planned to commence across Trafford Hospital from the end of October 2014. Once fully installed, observation charts will always be available electronically.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 Require liaison with Clinical Site Coordinators before arranging inter-site transfers to confirm bed availability.
Verbatim wording from the response “It has been agreed that in future all transfers between sites will not be arranged without liaison with the Clinical Site Coordinators to ensure that this unacceptable situation does not arise again.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address immediate post-fall family notification expectations with the Ward Manager.
Verbatim wording from the response “It is usual practice to notify the family immediately of a fall occurring on the ward. It is not acceptable that the family were not informed for 4 hours. The Trust would like to apologise for this and to reassure the family that this has been addressed with the Ward Manager. The Ward Manager now recognises that a call should have been made directly after the fall to inform his family, rather than waiting the outcome of the x-ray.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 Scan records for deceased patients and patients involved in high-level incidents into the electronic patient record as a priority.
Verbatim wording from the response “Trafford Hospital acknowledges that the loss of these nursing records is unacceptable. In order to minimise the risk of this issue arising again, a new process has been implemented by the Trafford Medical Records Manager that all records, including nursing charts, for any patient who has died and for any patient involved in a high level incident will be scanned into the electronic patient records (EPR) system as a priority.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 Monitor completion and updating of nursing risk assessments through daily matron rounds, ward-manager oversight and out-of-hours compliance reviews.
Verbatim wording from the response “The Head of Nursing for Trafford has taken steps to address this issue and has established robust monitoring processes. Matrons undertake daily rounds of the ward areas and review the completion of all nursing documentation; this review focuses specifically on the completion of appropriate risk assessments and helps raise awareness with staff. Ward Managers also have responsibility for ongoing monitoring of compliance in their areas. In addition, the Out of Hours team review compliance with the completion and updating of risk assessments at night and at weekends with any non-compliance being addressed at the time with the individuals concerned and highlighted to the Ward Manager or Matron.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 Develop and roll out the Chameleon electronic patient-record system across the Trust in stages.
Verbatim wording from the response “There is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust using a system called Chameleon. This will minimise the risks that documentation will be lost. The timeframe for this to be complete across the entire Trust is 2018. However, this is being developed and implemented in stages so it is likely that Trafford will be fully electronic before then.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 electronic patient records on Ward 16 so clinicians at both sites can access up-to-date notes without transferring paper records.
Verbatim wording from the response “Medical records at Trafford Hospital are electronic and are easily accessible to all medical staff at MRI on any computer. However, until February this year Ward 16, which is a ward based at Trafford but managed by Manchester Royal Infirmary, were still using paper documentation. This is why ████████ was unable to access Mr Maher's records. Ward 16 is now using the EPR system in line with the rest of Trafford Hospital. Therefore, up to date case notes are now available to Clinicians at both sites with no further need for transfer of paper notes between sites.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-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 Increase use of seat alarms for patients who do not comply with TAB alarms.
Verbatim wording from the response “The hospital has recently increased the use of seat alarms for those patients who are not compliant with the use of TAB alarms. These have a sensor which alarms when the patient stands up and are considered to be more reliable than the TAB alarm system for this patient group.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue embedding and refining the inter-site transfer process through ongoing review and small adjustments.
Verbatim wording from the response “Trafford Division acknowledges that since implementation of the New Clinical Model in November 2013, there has been a period of significant change and time needed for the new transfer process to be embedded. A transfer policy has been in place since the New Clinical Model was established but adherence to this policy was variable in the early stages. Continuous efforts have been made to ensure that this is fully embedded in practice and we can offer assurance that since the start of this new system there have been 485 patient transfers between the two sites with no instances of patient harm reported as a result. Trafford Division is confident that staff are aware of the transfer policy and that this has been communicated to them. The Division is continually reviewing and making small adjustments to the transfer process in order to make improvements.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation TAB alarms do not activate when unclipped; the patient removed this alarm himself, so the proposed alarm-failure premise is disputed.
Verbatim wording from the response “TAB alarms are useful only as part of the wider falls prevention strategy as they reduce rather than eliminate the risk of falling. TAB alarms are battery operated alarms which are clipped to the clothing and alert staff that a patient has started to mobilise independently when they are unsafe or unsteady to do so. It is not a feature of TAB alarms to activity if they are unclipped, only if they are pulled. They do not alarm to indicate that they are no longer offering protection. Mr Maher’s TAB alarm had been removed and placed on his bed. There is no indication that the TAB alarm was removed by a member of staff. Mr Maher told staff on the ward that he had removed it himself as he did not want to bother the staff.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist orthopaedic transfer was unnecessary because the fracture required bed rest, pain relief and pressure-area care available through nursing care on any ward.
Verbatim wording from the response “On 03 February 2014, ████████ agreed with ████████ view that Mr Maher should move to an Orthopaedic ward at Manchester Royal Infirmary as Mr Maher had a fractured pelvis. Mr Maher was not transferred on 03 February 2014, as previously explained, due to the unavailability of a bed. Mr Maher was discussed by the Trauma team at MRI on 04 February 2014. The team made the decision that Mr Maher did not require transfer to Manchester Royal Infirmary as he was confident that Mr Maher did not need to be on an Orthopaedic ward as he did not require any level of specialised orthopaedic care for his fracture. Mr Maher needed bed rest, pain relief and pressure area care, all of which can be provided through good nursing care on any ward.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ward 16 was considered capable of providing the required medical and nursing care despite specialising in complex discharge planning.
Verbatim wording from the response “Ward 16 is a ward which specialises in complex discharge planning. The Trust would like to reassure the family that the level of medical and nursing input on Ward 16 is as good as on a Medical ward and Ward 16 is able to manage patients with complex problems.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic records were accessible at both sites, so no further transfer of paper notes was considered necessary.
Verbatim wording from the response “Medical records at Trafford Hospital are electronic and are easily accessible to all medical staff at MRI on any computer. However, until February this year Ward 16, which is a ward based at Trafford but managed by Manchester Royal Infirmary, were still using paper documentation. This is why ████████ was unable to access Mr Maher's records. Ward 16 is now using the EPR system in line with the rest of Trafford Hospital. Therefore, up to date case notes are now available to Clinicians at both sites with no further need for transfer of paper notes between sites.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
Concerns raised 3 Inconsistent referral of unwell A&E attenders to a psychiatrist View source Lack of age-appropriate observation guidance for children and adolescents in specialist mental health units View source Lack of formal communication and information-transfer protocols between healthcare establishments 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
Miss Samiyo Sahra Shih Farah · 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
Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent referral of unwell A&E attenders to a psychiatrist
Wider context from the report “3) There appears to have been an inconsistency of approach following Miss Farah’s admissions to A & E. She was referred directly to a Psychiatrist on the second attendance when she was clearly unwell but had not managed to self-harm but was not on the first attendance when she had taken an overdose . This also raises the question as to whether she ought to have been referred (to a Psychiatrist) on the 31st October 2012 .
” 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 age-appropriate observation guidance for children and adolescents in specialist mental health units
Wider context from the report “1) Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units . At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues . The care needs of young people are quite different to those of adults .
” 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 formal communication and information-transfer protocols between healthcare establishments
Wider context from the report “2) Communication/contact between transferring establishments - there is no formal policy/protocol in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors , thus risking that not all key information (both verbal and written) is properly communicated before, during and after transfer . Whilst progress is being made in this regard at local level following the death of Miss Farah (and may well be the basis upon which any national policy/protocol might be formulated) there is currently no communication/transfer protocol in existence . This also potentially impacts upon all other healthcare sector providers e.g. the acute sector, hospital to care home, acute to rehabilitation/community services etc.
” Open source report
Concerns raised 2 Contradictory messages from nursing and medical staff View source Lack of a clear policy to determine candecy 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
STEPHEN GOODHALL · 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 Goodhall fell at home on 19 October 2013, fractured his lumbar spine, developed recurrent hospital-acquired pneumonia and deteriorating physiological and kidney function, and died two days after being taken to ITU. The report identified concerns about the absence of a clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff.
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 Contradictory messages from nursing and medical staff
Wider context from the report “There does not appear to be a clear policy in place to determine candecy and there appears to have been a contradictory message from the nursing and medical staff .
” 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 policy to determine candecy
Wider context from the report “There does not appear to be a clear policy in place to determine candecy and there appears to have been a contradictory message from the nursing and medical staff.
” Open source report
Pin
Request correction
Addressed to University Hospital of South Manchester 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