16 Dec 2025 Walter Perukeno POLLYN · Prevention of Future Deaths report Kent and Medway
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Concerns raised 2 Failure to prevent water access for patients who are nil by mouth View source Failure to make patient record completion reflect individual care instructions View source
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AI-generated summary
Walter Perukeno POLLYN · 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
Walter Pollyn was admitted after an unwitnessed fall and increased confusion, tested positive for Covid-19, and was later placed nil by mouth because of oropharyngeal dysphagia. Water was repeatedly left within his reach, and he aspirated water on 24 July 2024 before his condition deteriorated. He died in hospital on 16 August 2024; the immediate cause was multifactorial pneumonia, including aspiration pneumonia. The principal concerns were repeated staff failure to follow the nil-by-mouth instruction and possible underlying attitudinal and record-keeping issues that allowed unsupervised access to water to persist.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent water access for patients who are nil by mouth
Wider context from the report “(1) Having been made 'nil by mouth', the evidence was that this was well documented in Mr Pollyn's records, a sign indicating that he was nil by mouth was placed above his bed, and the board within the ward kitchen was also updated. Despite this, the records indicate that numerous members of nursing staff ensured that water was placed at Mr Pollyn's bedside (which would be standard practice were Mr Pollyn not 'nil by mouth' at the time). While the Trust has updated the relevant policies and sought to disseminate messaging to staff in this regard, I was not reassured that this is solely a matter of policy. The number of staff involved and the period of time over which the issue of unsupervised access to water persisted is potentially suggestive of underlying attitudinal issues.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make patient record completion reflect individual care instructions
Wider context from the report “(2) Following on from the above, I heard in evidence that the production of some patient records is a simple tick-box exercise , which is not a concern in itself. However, the impression created by the evidence was that staff members were ticking the box to indicate that water was placed/replaced at the bedside (and following through on that action) because that was the norm for most patients on the ward . This indicates that staff missed the entries in the notes about 'nil by mouth' and the other visual cues that were clear . While I heard that the Trust intends to undertake a review of record keeping, which may not be completed until March 2026, I was given insufficient reassurance that this specific concern is being addressed.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise bedside signage, tracking-board flags, water restrictions and documentation prompts for nil-by-mouth patients.
Verbatim wording from the response “• Clear visual controls and environmental safeguards, including revised bedside signage, tracking board flags, and standardised prompts, aim to reduce reliance on memory or assumptions. These include standardised bedside signage stating ‘supervised water only,’ removal of unsupervised water jugs, visible ‘nil by mouth’ indicators on electronic patient tracking boards, and clear documentation prompts. All signage and visual controls are being standardised through the Fundamental Standards of Care Group.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore automated electronic patient-record alerts for conflicting nil-by-mouth documentation and recorded water provision.
Verbatim wording from the response “• Digital system improvements, including exploration of automated electronic patient record (EPR) alerts to identify documentation conflicts, such as when provision of water is recorded for a patient marked as ‘nil by mouth’.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide targeted face-to-face nil-by-mouth, supervised-water and aspiration-risk training, reinforced through care study days, handovers and safety huddles.
Verbatim wording from the response “• Targeted education and training to enhance staff understanding of ‘nil by mouth’ status, supervised sips of water, and the clinical risks related to aspiration. This training is provided face-to-face alongside nutrition and hydration education, reinforced through Harm-Free Care study days, daily ward handovers, and safety huddles. Training compliance is tracked via a central training database.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce patient safety outcomes, rather than task completion, as the measure of success.
Verbatim wording from the response “These insights have informed a series of high-impact actions already in progress, including:” Source location Response from Medway NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a structured nil-by-mouth checklist for non-procedural patients.
Verbatim wording from the response “• Introduction of a structured ‘nil by mouth’ checklist for non-procedural patients to minimise practice variations and ensure key safety steps are not overlooked.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct recurring Trust-wide audits of nil-by-mouth care and escalate findings through safety and quality governance.
Verbatim wording from the response “A detailed Trust-wide ‘nil by mouth’ care improvement action plan has been developed and implemented to directly address the potential gaps identified during the Inquest. This action plan includes:” Source location Response from Medway NHS Foundation Trust
Open published response
15 Nov 2022 Sally-Ann Few · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 5 Failure to prescribe the patient's established Zoromorph medication View source Failure of medical staff to document clinical decisions, discussions and advice View source Absence of electronic-record alerts for required medication discrepancy reviews View source Failure of the prescribing system to record discontinued Oromorph prescriptions View source Failure to review identified medication discrepancies View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sally-Ann Few · 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
Sally-Ann Few was found dead at home on 12 March 2022, after being discharged from hospital the previous day with both slow-release and faster-acting morphine; a post-mortem found that she died as a consequence of morphine toxicity. Concerns included the GP prescribing system not showing that Oromorph had been stopped, a discrepancy between inpatient morphine prescriptions that was not reviewed, and poor medical record keeping that did not document decision-making, discussions, or advice.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe the patient's established Zoromorph medication
Wider context from the report “(2) Evidence was heard that Mrs. Few whilst an inpatient was prescribed Oromorph and not Zoromorph the drug she had been using at 20mg twice a day . The effect of which may have impacted upon her pain control but the evidence did not show she had high pain scores. A pharmacist recognised this discrepancy on 8th March and asked for this to be reviewed. No such review took place and it was difficult to see on the electronic records system that such a review needed to take place as apparently there were no highlights or flags to alert the doctors that such a review needed to take 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to document clinical decisions, discussions and advice
Wider context from the report “(3) At the inquest it was clear that the standard of record keeping by the medical staff was poor and it was only by hearing from witnesses via statements and orally, including from her family, that the decision making around her care and plans for her management became clear, as there was very little written in the notes . In particular there was no evidence of why decisions were made, what discussions were held and what advice was 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of electronic-record alerts for required medication discrepancy reviews
Wider context from the report “(2) Evidence was heard that Mrs. Few whilst an inpatient was prescribed Oromorph and not Zoromorph the drug she had been using at 20mg twice a day. The effect of which may have impacted upon her pain control but the evidence did not show she had high pain scores. A pharmacist recognised this discrepancy on 8th March and asked for this to be reviewed. No such review took place and it was difficult to see on the electronic records system that such a review needed to take place as apparently there were no highlights or flags to alert the doctors that such a review needed to take 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the prescribing system to record discontinued Oromorph prescriptions
Wider context from the report “(1) Evidence given at the inquest revealed that the system at the GP practice when examined by the pharmacist at the hospital did not show that the Oromorph prescription had been stopped .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review identified medication discrepancies
Wider context from the report “(2) Evidence was heard that Mrs. Few whilst an inpatient was prescribed Oromorph and not Zoromorph the drug she had been using at 20mg twice a day. The effect of which may have impacted upon her pain control but the evidence did not show she had high pain scores. A pharmacist recognised this discrepancy on 8th March and asked for this to be reviewed. No such review took place and it was difficult to see on the electronic records system that such a review needed to take place as apparently there were no highlights or flags to alert the doctors that such a review needed to take place.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind pharmacy staff to follow medicines recommendations through to a conscious decision to endorse or reject them.
Verbatim wording from the response “In the interim, Pharmacy staff have been reminded that their professional responsibility does not end with a note flagging a potential medicines issue, but there is an expectation that recommendations should be followed through to a conscious decision to either endorse or reject a recommendation.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop auditable electronic prescribing functionality that alerts doctors when pharmacists identify issues requiring review.
Verbatim wording from the response “The EPMA system is being continuously developed and enhanced to improve patient safety, and whilst there is a section now included for Pharmacists to add notes to electronic prescriptions, the Trust is seeking to develop” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate how primary-care morphine changes were recorded, communicated and reflected in the Kent Summary of Care Record.
Verbatim wording from the response “The Trust Pharmacy team has contacted representatives of the Kent & Medway ICB Medicines Optimisation team that cover Medway & Swale. They are currently investigating the review process by the pharmacist to understand how the dose and product changes made were recorded and communicated to the GP practice. They are also investigating why these changes did not appear in the Kent Summary of Care Record.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind ENT clinicians to document daily treatment decisions and the reasons for those decisions.
Verbatim wording from the response “Sally-Ann Few (Sally-Ann Bester) was seen by either a consultant or another senior ENT doctor on a daily basis during her inpatient stay as part of the daily ward rounds. The daily decisions taken regarding treatment of her airway condition were documented. The reasons for the decisions were clear to the treating team, but may be less clear to clinicians and others who were not team members and the ENT clinicians have been reminded of the need to both continue to document decisions on the daily ward round and additionally document the reasons why the decisions were made. The electronic discharge summary completed on 11th March 2022 did explain the decision making process and the options that had been discussed.” Source location Response from Medway NHS Foundation Trust
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25 Apr 2022 Kathryn Lynda Millard · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 6 Failure to maintain identification of the attending clinician View source Failure to communicate prescribed anti-embolic stocking instructions to nursing staff View source Failure to record clinical attendance and patient assessment in the medical records View source Failure to document senior clinician treatment directions in the medical records View source Failure to implement senior clinician treatment directions View source Failure to discuss patient presentation and prognosis with nursing staff View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Kathryn Lynda Millard · 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
Kathryn Lynda Millard fell down stairs at a property where she was working on 10 May 2021 and was admitted to hospital with a fractured spine. She later developed green vomit, suffered a cardiac arrest on 13 May 2021, and could not be resuscitated; the jury recorded pulmonary embolism and deep venous thrombosis as the medical cause of death. Concerns included failure to document and implement a senior clinician’s direction, lack of awareness among nursing staff about anti-embolic stockings, and inadequate recording and communication following a review of her deteriorating presentation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain identification of the attending clinician
Wider context from the report “(3) The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs Millard’s medical records. It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate prescribed anti-embolic stocking instructions to nursing staff
Wider context from the report “(2) The medical records indicated that at least one doctor had indicated that Mrs Millard should have anti-embolic stockings applied. However, the nursing staff gave evidence that they were not aware of this .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical attendance and patient assessment in the medical records
Wider context from the report “(3) The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs Millard’s medical records . It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document senior clinician treatment directions in the medical records
Wider context from the report “(1) The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented. It is concerning that this treatment plan was not recorded properly in the deceased’s notes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement senior clinician treatment directions
Wider context from the report “(1) The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented . It is concerning that this treatment plan was not recorded properly in the deceased’s notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss patient presentation and prognosis with nursing staff
Wider context from the report “(3) The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs Millard’s medical records. It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing staff .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver safety messages and local teaching to nurses about escalating indicated but unprescribed appliances.
Verbatim wording from the response “The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an annual Trust-wide audit of healthcare record keeping, including compliance with relevant Trust policy.
Verbatim wording from the response “An audit of healthcare record keeping (including compliance with relevant Trust policy) will take place on an annual basis Trust wide. In addition, compliance with the expected documentation standards are included in the Ward to Board Assurance and Accreditation Process, which will be rolling out from 27 June 2022.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake ongoing regular record-keeping audits through the Trust Gather reporting system and use findings to inform local audit programmes.
Verbatim wording from the response “The results of such audits will be reported via the Trust’s Governance structures for Quality, including outcomes and exceptions. In addition, ongoing regular audits will be undertaken using the Trust ‘Gather’ reporting system by Care Groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind all staff to record every patient contact in the medical record in line with national and Trust guidelines.
Verbatim wording from the response “As you highlighted, the Trust was unable to ascertain if Mrs Millard was indeed assessed by a clinician on 12 May 2021 when her condition deteriorated as there is no record of this care taken place. This does not meet the standards we would expect and all staff have been reminded that all patient contacts are to be recorded in the patient medical record in line with national and Trust guidelines.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out documentation standards within the Ward to Board Assurance and Accreditation Process.
Verbatim wording from the response “An audit of healthcare record keeping (including compliance with relevant Trust policy) will take place on an annual basis Trust wide. In addition, compliance with the expected documentation standards are included in the Ward to Board Assurance and Accreditation Process, which will be rolling out from 27 June 2022.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the Serious Incident Investigation findings at the junior doctor grand round.
Verbatim wording from the response “In relation to the concern of poor record keeping by the medical doctor, the Orthopaedic team have discussed the outcome of the Serious Incident Investigation report at the junior doctor’s grand round.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit anti-embolic stocking practice monthly, monitor compliance during ward and drug rounds, and share identified lessons at ward meetings.
Verbatim wording from the response “Since the recipient of this letter, the team has again sent out safety message to all nursing staff as a reminder of the expected standard. Compliance with expected practice will be audited monthly, and monitored during ‘Ward Rounds’ and ‘Drug Rounds’ and lessons identified will be shared at ward meetings.” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind medical doctors of required healthcare record-keeping standards.
Verbatim wording from the response “Medical doctors have been reminded of the importance and principles of effective healthcare record keeping, which is a minimum standard. The quality of records should meet the Generic Record Keeping Standard, General Medical Record keeping Standards (Royal Academy of Physicians) and Standards for the structure and content of patient records (Academy of Medical Royal Colleges).” Source location Response from Medway NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit adherence to national and Trust record-keeping standards monthly and share results through local and divisional governance boards.
Verbatim wording from the response “The adherence to national and Trust standards will be audited on a monthly basis and the results of the audit will be shared at local and divisional governance board meetings to ensure compliance and improvement in practice.” Source location Response from Medway NHS Foundation Trust
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report record-keeping audit results through the Trust’s quality governance structures, including outcomes and exceptions.
Verbatim wording from the response “The results of such audits will be reported via the Trust’s Governance structures for Quality, including outcomes and exceptions. In addition, ongoing regular audits will be undertaken using the Trust ‘Gather’ reporting system by Care Groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.” Source location Response from Medway NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure anti-embolic stockings are prescribed and applied when clinically indicated.
Verbatim wording from the response “The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed.” Source location Response from Medway NHS Foundation Trust
Open published response
11 Jul 2021 Johanna Marie MORELAND · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Delays in making lumbar puncture results available View source Failure to carry out required observations following liver biopsy View source Failure to record required observation levels in medical records View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Johanna Marie MORELAND · 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
Johanna Marie Moreland died on 8 March 2021 at Medway Maritime Hospital following intra-abdominal haemorrhage after a liver biopsy, in the context of advanced hepatocellular carcinoma. Concerns included delays in receiving lumbar puncture results and starting antiviral treatment, and failure to follow or record required observations after the biopsy due to miscommunication between Trust staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in making lumbar puncture results available
Wider context from the report “(1) Results from lumbar puncture taken on 26th February 2021 were made available on 4th March 2021 . Evidence heard at the inquest was that Lumbar Puncture tests are usually for diagnosis of serious illness and would usually be made available within 24-48 hours .
(2) The Lumbar Puncture results were positive for encephalitis and in the absence of the tests results, a liver biopsy was conducted and, there was a delay in antiviral treatment commencing .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required observations following liver biopsy
Wider context from the report “(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record required observation levels in medical records
Wider context from the report “(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a post-procedure handover form for use after every procedure.
Verbatim wording from the response “This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.” Source location 2021-0240-Response-from-Medway-Maritime-Hospital_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.
Verbatim wording from the response “This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.” Source location 2021-0240-Response-from-Medway-Maritime-Hospital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reiterate the post-procedure observation policy to nursing staff through recurring Big 4 ward messaging.
Verbatim wording from the response “This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.” Source location 2021-0240-Response-from-Medway-Maritime-Hospital_Published
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The viral lumbar puncture results were received within the normal turnaround time for this outsourced investigation.
Verbatim wording from the response “The Trust has investigated the timeframe for the availability of Mrs Moreland’s results. The cerebrospinal fluid (CSF) sample was taken on Friday 26th February 2021 and was received at the Pathology department at 17:28 on the same evening. The standard cell count, protein and glucose levels and bacterial screening and culture, performed in our microbiology laboratory at North Kent Pathology Services based at Dartford, was available within normal turnaround time of 24-48hrs and was unremarkable.” Source location 2021-0240-Response-from-Medway-Maritime-Hospital_Published
Open published response
23 Apr 2021 Derek Albert RUSSELL · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1 Chronic shortages of falls alarm equipment for patients assessed as requiring it View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Derek Albert RUSSELL · 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
Derek Albert Russell, who had a history of falls, was admitted to hospital after an unwitnessed fall and was assessed as being at high risk of further falls. Despite repeated requests, falls alarm equipment was unavailable, and he later suffered another unwitnessed fall and brain haemorrhages before developing COVID-19 and dying. The principal concern was the chronic shortage of falls alarm equipment at Medway Maritime Hospital, which increased patients’ risk of falls and serious injury and compromised clinical staff’s ability to monitor and reduce that risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Chronic shortages of falls alarm equipment for patients assessed as requiring it
Wider context from the report “I am concerned that:
(a) Patients who are assessed as requiring falls alarm equipment in future will not receive it due to chronic shortages of that equipment in the Medway Maritime Hospital.
(b) By failing to provide adequate falls alarm equipment , patients are at increased risk of falling and sustaining fatal injuries (or injuries such as fractures and brain injury that can lead to immobility, susceptibility to infection and death).
(c) The ability of clinical staff to monitor and reduce the risk of patients falling and sustaining fatal injuries is seriously compromised by the lack of this basic safety equipment and is putting lives at risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Purchase additional falls alarms, bed sensor pads and chair sensor pads to increase available equipment.
Verbatim wording from the response “Since 2015 Medway NHS Foundation Trust has purchased 236 falls alarms, the last purchase being 100 alarms available for use February 2020 with each ward being allocated two dedicated falls alarms. Our Frailty Assessment Unit has also purchased nine additional alarms, and in response to the concerns raised by HM Coroner the Trust is in the process of increasing stock by purchasing a further 75 falls alarms, 75 bed sensor pads, and 10 chair sensor pads.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 and require compliance with the falls-equipment procurement and non-availability escalation procedure.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 Clinical Engineering to notify the dedicated falls team of shortages and provide twice-yearly stock reports and annual stocktakes.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 ward-level stocktaking, local stock monitoring and daily checks alongside the centrally held falls-equipment reserve.
Verbatim wording from the response “Our comprehensive investigation following this Regulation 28 report identified that the tracking of stock throughout the hospital was not as robust as it could be, and as such changes are being implemented to stocktake current provisions and equip wards with the ability to monitor and maintain their own stock in addition to the centrally held reserve; falls equipment levels and availability will be added to the daily checks each ward completes. Budget will be identified and Clinical Engineering, who maintains the equipment stores, will be establishing a robust process for the RFID tagging, logging and tracking of falls equipment as they do with other critical equipment. We have also contacted other local Trusts to learn from any helpful processes they have in place.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 10 dedicated, tracked falls alarms in the Emergency Cupboard at all times.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 Identify budget and establish RFID tagging, logging and tracking for falls equipment.
Verbatim wording from the response “Our comprehensive investigation following this Regulation 28 report identified that the tracking of stock throughout the hospital was not as robust as it could be, and as such changes are being implemented to stocktake current provisions and equip wards with the ability to monitor and maintain their own stock in addition to the centrally held reserve; falls equipment levels and availability will be added to the daily checks each ward completes. Budget will be identified and Clinical Engineering, who maintains the equipment stores, will be establishing a robust process for the RFID tagging, logging and tracking of falls equipment as they do with other critical equipment. We have also contacted other local Trusts to learn from any helpful processes they have in place.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 Remind appropriate staff to report and escalate falls-equipment shortages promptly.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 up-to-date falls-equipment training for staff working predominantly nights.
Verbatim wording from the response “Since January 2019 there have been 9 reports of inability to obtain a falls alarm, with all incidents occurring overnight. Escalation of these incidents to the dedicated falls team did not always happen, but where they were alerted additional alarms were purchased in response. The occurrence of the majority of these incidents being overnight has led to the Trust ensuring training is up” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
Open published response
3 Feb 2021 CHRISTOPHER SMITH · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 13 Unsafe and unhygienic home conditions, including leaks and exposed electrical wiring View source Failure to complete recommended home assessments before discharge View source Failure to make district nurse referrals for specialist wound care View source Failure to reassess fluctuating mental capacity View source Failure to verify community care arrangements at discharge View source Failure to act on safeguarding alerts View source Failure to inform families of discharge home when care is required View source Incomplete and inaccurate discharge nursing documentation View source Absence of a bed in the home View source Incorrect recording of next-of-kin information in medical records View source Failure to respond appropriately to deterioration while patients remain on discharge wards View source Failure to establish capacity before decisions about care and treatment View source Failure to provide dietary requirements adequate for patients’ needs View source See 10 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
CHRISTOPHER SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe and unhygienic home conditions, including leaks and exposed electrical wiring
Wider context from the report “(6) Transport staff returning Mr Smith home found he had no key. One was located and on entering the property found conditions that caused them serious concern about the hygiene and health and safety within the property with a leak, uncleanliness and exposed electrical wiring and that there was no bed.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete recommended home assessments before discharge
Wider context from the report “(1) A recommended home assessment was not completed as part of Mr Smith’s planned 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make district nurse referrals for specialist wound care
Wider context from the report “(5) Mr Smith has extensive leg ulcers that required specialist input. No district nurse referral was made to ensure that Mr Smith’s leg ulcers were treated.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess fluctuating mental capacity
Wider context from the report “(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition. Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify community care arrangements at discharge
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on safeguarding alerts
Wider context from the report “(7) Transport staff were informed by the hospital not to return Mr Smith to the hospital as there was no bed available and they therefore raised a safeguarding alert. The safeguarding alert was not acted upon and Mr Smith was found by family after five days lying on the floor of his home with no dressing on his legs, unable to move and with no access to food or drink.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform families of discharge home when care is required
Wider context from the report “(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete and inaccurate discharge nursing documentation
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect , and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a bed in the home
Wider context from the report “(6) Transport staff returning Mr Smith home found he had no key. One was located and on entering the property found conditions that caused them serious concern about the hygiene and health and safety within the property with a leak, uncleanliness and exposed electrical wiring and that there was no bed .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect recording of next-of-kin information in medical records
Wider context from the report “(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond appropriately to deterioration while patients remain on discharge wards
Wider context from the report “(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition . Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish capacity before decisions about care and treatment
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide dietary requirements adequate for patients’ needs
Wider context from the report “(8) On readmission to hospital his dietary requirements were not adequate for his needs .
” Open source report
1 Feb 2021 BETTY ANNIE TADMAN · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 7 Failure to consider fracture or internal bleeding during continued deterioration View source Failure to conduct imaging after a fall to establish injury View source Failure to conduct a serious incident investigation after a death View source Failure to consider potential fracture injury View source Over-reliance on absence of reported pain during physical examination View source Failure to consider the circumstances of a fall during clinical assessment View source Failure to review cases and learn lessons through morbidity and mortality or other forums View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BETTY ANNIE TADMAN · 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
Betty Annie Tadman died after an unwitnessed fall at home caused a pelvic fracture with extensive local haemorrhage. She was treated for suspected urosepsis and deep vein thrombosis, but no imaging was conducted despite signs of possible injury, and the pelvic fracture and internal bleeding were not diagnosed. Concerns were also raised that the Trust did not investigate the death or review it through its morbidity and mortality processes.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider fracture or internal bleeding during continued deterioration
Wider context from the report “5. There was no consideration of potential fracture or internal bleeding in the presence of dropping of haemoglobin and continued deterioration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct imaging after a fall to establish injury
Wider context from the report “3. Mrs Tadman was an elderly lady with a medical history of osteoporosis who fell from a standing height. No imaging was conducted on admission to hospital to establish if Mrs Tadman had sustained an injury.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a serious incident investigation after a death
Wider context from the report “6. The Trust did not conduct a serious incident investigation following Mrs Tadman’s death when the post-mortem cause of death established a pelvic fracture with severe haemorrhage. Evidence heard at the inquest confirmed that this case was not discussed at the trust morbidity and mortality review or any other forum giving rise to concerns that lessons had not been learned.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider potential fracture injury
Wider context from the report “2. Evidence was heard at the inquest that ambulance crew noted and handed over Mrs Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on absence of reported pain during physical examination
Wider context from the report “4. Swelling in the calves gave rise to a suspicion of potential deep vein thrombosis and dalteparin was prescribed. Physical examination was over reliant on the lack of complaints of pain in a patient with dementia in the absence of imaging.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the circumstances of a fall during clinical assessment
Wider context from the report “1. Mrs Tadman had dementia and a long-term catheter who was admitted to hospital with a pre-alert for suspicion for urosepsis that was treated appropriately. However, urine dipstick tests were only positive for blood and consideration was not given to the circumstances in which she was found with a history of a fall .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review cases and learn lessons through morbidity and mortality or other forums
Wider context from the report “6. The Trust did not conduct a serious incident investigation following Mrs Tadman’s death when the post-mortem cause of death established a pelvic fracture with severe haemorrhage. Evidence heard at the inquest confirmed that this case was not discussed at the trust morbidity and mortality review or any other forum giving rise to concerns that lessons had not been learned .
” 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 ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Verbatim wording from the response “2.3. The Trust is committed to implementing the “silver trauma” screening system in ED for frail patients presenting with ‘low energy’ trauma with an assessment led by a senior clinician (ST 4 +) if there are any red flags signs for escalation.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Verbatim wording from the response “2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major Trauma Patients – Second Edition whereby trauma units use an effective screening triage tool on elderly patients who self-present or arrive by ambulance and this prompts an immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we have already introduced a “front door” team of specialist nurses to assess elderly frail patients upon arrival in ED to expedite their transfer to the ward or escalate for medical advice or discharge as appropriate.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 Have the Medical Examiner review post-mortem reports and route identified concerns through the Patient Safety and Learning from Deaths programmes.
Verbatim wording from the response “2.6. Since publication in July 2018 of the National Quality Board (NHSE) Learning from Deaths Guidance, the Trust Board is committed to embedding a culture of learning and ensuring effective implementation of all aspects of learning from death. The Trust Mortality Team has initiated a system with the local Coroners Court to ensure all post mortem reports are now disclosed promptly following any patient’s death in hospital. The Medical Examiner also now reviews PM Reports, to ensure that any concerns are highlighted through the Trust’s Patient Safety programme via a link with the Trust Learning from Deaths Team. All post mortems will now be shared with the doctor making the referral to the Coroner and the responsible Consultant.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 staff teaching and simulated training on evidence-based trauma care for elderly patients.
Verbatim wording from the response “2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been undertaken on improving trauma care of the elderly with a focus on the emerging evidence-based pathway of “silver trauma” care. This training programme, which included simulated exercises, is currently suspended but will be resumed shortly.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 Present the case and learning at a multidisciplinary Grand Round, reminding clinicians to interpret D-Dimers with the recognised screening tool.
Verbatim wording from the response “2.4. The facts and identified failures in this matter will be presented as a case study at a Multi-disciplinary Grand Round session, as soon as they resume, for teaching purposes when clinicians will be reminded that D-Dimers are not to be used in isolation but in conjunction with the recognised screening tool.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
Verbatim wording from the response “2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major Trauma Patients – Second Edition whereby trauma units use an effective screening triage tool on elderly patients who self-present or arrive by ambulance and this prompts an immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we have already introduced a “front door” team of specialist nurses to assess elderly frail patients upon arrival in ED to expedite their transfer to the ward or escalate for medical advice or discharge as appropriate.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 Resume the suspended staff teaching and simulated training programme on elderly trauma care.
Verbatim wording from the response “2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been undertaken on improving trauma care of the elderly with a focus on the emerging evidence-based pathway of “silver trauma” care. This training programme, which included simulated exercises, is currently suspended but will be resumed shortly.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ambulance record documented a shortened leg without rotation, contrary to the inquest evidence.
Verbatim wording from the response “1.2. Evidence was heard at the Inquest that ambulance crew noted and handed over that Mrs Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury. (The Trust wishes to point out that in fact the ambulance record documented shortening but no rotation)” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
21 Feb 2020 LUKE OWEN JACKSON · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete View source Inadequate treatment of total body potassium depletion with gastroenteritis resuscitation View source Failure to recognise total body potassium depletion in unwell children with myopathies View source Atypical presentation of respiratory distress in children with myopathies weakened by low potassium 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
LUKE OWEN JACKSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks:
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk.
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress.
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate treatment of total body potassium depletion with gastroenteritis resuscitation
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks :
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk .
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress.
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise total body potassium depletion in unwell children with myopathies
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell . They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks:
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk.
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress.
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Atypical presentation of respiratory distress in children with myopathies weakened by low potassium
Wider context from the report “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart.
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks:
(i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell.
(ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate.
(iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk.
(iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress .
(v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update paediatric guidelines to strengthen recognition, senior assessment, monitoring and management of children with myopathies and hypokalaemia, including STRS contact indications.
Verbatim wording from the response “The Trust has updated their Paediatric Guidelines (GUDPCM016) in response to patients with myopathies to reflect that:” Source location 2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
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 and publish a paediatric guideline algorithm for recognising and managing low potassium.
Verbatim wording from the response “2 | Develop a guideline for recognition and management of low K+ on the paediatric ward. | Improved monitoring enabling better management and care to be delivered. | Paediatric Consultant | The full algorithm has been prepared and was ratified through clinical governance procedure. Page 94 and 95 of Paediatric Guidelines.” Source location 2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
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 Highlight abnormal electrolyte results during handover and escalate them to a consultant for oversight.
Verbatim wording from the response “1 | Ensure abnormal results are recognised and escalated to Consultant. | Improved monitoring enabling better management and care to be delivered. | Paediatric Consultant | Abnormal results, particularly electrolyte abnormalities are highlighted at hand-over.” Source location 2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing STRS guidance does not require referral for every child with serum potassium below 3.0.
Verbatim wording from the response “The Trust has also updated their Paediatric Guidelines with regards to the indications for contacting the STRS in children with hypokalaemia and contacting STRS. Our STRS link, Dr ████████ who has agreed that STRS do not expect to be contacted for all children with a serum K < 3.0. The use of dilute peripheral solution for potassium remains safe and first line option in District General Hospital settings in appropriately chosen patients.” Source location 2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dilute peripheral potassium replacement remains a safe first-line option in appropriately selected district general hospital patients.
Verbatim wording from the response “The Trust has also updated their Paediatric Guidelines with regards to the indications for contacting the STRS in children with hypokalaemia and contacting STRS. Our STRS link, Dr ████████ who has agreed that STRS do not expect to be contacted for all children with a serum K < 3.0. The use of dilute peripheral solution for potassium remains safe and first line option in District General Hospital settings in appropriately chosen patients.” Source location 2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
Open published response
19 Oct 2018 John Edward LEE · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Lack of checking procedures for appointment priority errors View source Lack of direct clinical-grade staff input into setting urgent appointments View source Ambiguity in wording urgent vascular appointments 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
John Edward LEE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Edward LEE died on the operating table during emergency open repair of a tender abdominal aortic aneurysm, following major blood loss, ventricular tachycardia and cardiac arrest. The report identifies a clerical error that resulted in his urgent vascular appointment being scheduled five weeks later than intended, and concerns about ambiguous appointment wording, insufficient clinical input into urgent bookings and the lack of a checking procedure for errors or misunderstandings of priority.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checking procedures for appointment priority errors
Wider context from the report “(3) There should be consideration given to a checking procedure to guard against human error or misunderstanding of priority
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of direct clinical-grade staff input into setting urgent appointments
Wider context from the report “(2) There should be provision for the direct input of clinical grade staff in setting clinical especially urgent appointments
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in wording urgent vascular appointments
Wider context from the report “(1) The use of the expression “next vascular slot” is uncertain and open to mis-interpretation
” Open source report
17 May 2018 BERNARD JOHN FAGG · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1 Failure to consider intravenous fluids after contrast CT before a prolonged nil-by-mouth procedure 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
BERNARD JOHN FAGG · 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
Bernard John Fagg was admitted to hospital with breathlessness and several suspected conditions, including heart failure, anaemia, fast atrial fibrillation and possible asbestos-related interstitial lung disease. After a contrast CT scan and an endoscopy, he developed acute kidney injury and died on 14 December 2017; clinicians attributed the death to contrast-induced nephropathy. The principal concern was whether intravenous fluids should have been considered because the endoscopy, requiring nil by mouth, took place shortly after the contrast CT scan.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider intravenous fluids after contrast CT before a prolonged nil-by-mouth procedure
Wider context from the report “Given the proximity of the endoscopy (which required nil by mouth) to the CT with contrast, the concern which arises is whether Mr Fagg should have been considered for and given intravenous fluids .
The doctor who gave evidence said that having requested an endoscopy he would not necessarily have known when this procedure would take place. It is not suggested that the endoscopy should not have taken place but during the course of the evidence the doctor did raise the point that had he known that the endoscopy was to take place the day after the CT scan with contrast he may have considered intravenous fluids .
The matter of concern is therefore whether a patient, even with normal renal function, should be considered for intravenous fluids in cases where they have had a CT scan with contrast and within a short time frame thereafter are required to undergo a procedure which will necessarily mean they will not be allowed to eat or drink for several hours .
” Open source report
10 Aug 2017 Claire Joan Elizabeth MEDHURST · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2 Failure to provide cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge View source Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Claire Joan Elizabeth MEDHURST · 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
Claire Medhurst was admitted after a polypharmacy overdose, was discharged after treatment, and was readmitted with abdominal pain and severe liver abnormalities. Her acute liver failure was not recognised or treated for about six hours before she deteriorated and died on 24 February 2017. Concerns included the lack of cautionary advice about further use of paracetamol or ibuprofen at discharge and the failure of the laboratory to alert clinicians to abnormal results and toxic paracetamol levels.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge
Wider context from the report “(1) The discharge process on 25th January 2017 did not include any cautionary advice as to the further use of medications such as paracetamol or ibuprofen as an analgesic particularly when Claire Medhurst had been experiencing headaches shortly before discharge and had been prescribed ibuprofen
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol results
Wider context from the report “(2) The treating clinicians did not receive an alert from the haematology laboratory for the abnormal results for ALT and toxic levels of paracetamol
” 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 Discuss overdose medication safety advice in Emergency Department daily safety huddles.
Verbatim wording from the response “2. The importance of providing essential information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol upon discharge has been discussed in the Emergency Department daily safety huddles to ensure that all members of staff are aware of the importance of providing such information.” Source location 2017-0270-Response-by-Medway-NSH-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 staff to document discharge advice given to overdose patients in medical notes.
Verbatim wording from the response “3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practice can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained.” Source location 2017-0270-Response-by-Medway-NSH-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 Ratify, print and distribute the overdose information leaflet through Emergency Department discharge planning, with documented explanation and subsequent audit.
Verbatim wording from the response “4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017. Once ratified, leaflets will be printed and available in the ED on 23rd October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2.” Source location 2017-0270-Response-by-Medway-NSH-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 Brief Emergency Department and acute assessment staff on paracetamol and ibuprofen safety advice for overdose patients.
Verbatim wording from the response “1. All key relevant staff will receive feedback via the appropriate staff meeting. These meetings are already scheduled and all clinicians within the Emergency Department and the acute assessment areas will receive the information through the staff briefings. All staff will be given an overview of the case and the importance of providing essential information to patients and their families on the use of drugs containing paracetamol and ibuprofen will be detailed.” Source location 2017-0270-Response-by-Medway-NSH-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 Conduct monthly audits of documented overdose medication advice until practice is assured to be embedded and sustained.
Verbatim wording from the response “3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practice can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained.” Source location 2017-0270-Response-by-Medway-NSH-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 an information leaflet explaining paracetamol overdose and medication precautions.
Verbatim wording from the response “4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017. Once ratified, leaflets will be printed and available in the ED on 23rd October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2.” Source location 2017-0270-Response-by-Medway-NSH-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 Audit compliance with SBAR reporting and associated critical-result protocols.
Verbatim wording from the response “3. An audit will be conducted in October 2017 to measure compliance with SBAR and the associated protocols, and ensure Trust procedures are being adhered to.” Source location 2017-0270-Response-by-Medway-NSH-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 nurse-in-charge review of every overdose patient before transfer or discharge, incorporating the requirement into the revised operating framework.
Verbatim wording from the response “5. All patients with an overdose must be reviewed by the nurse in charge of the department/acute assessment wards prior to their transfer or discharge. This will ensure that the patients’ medical management and discharge plan has been fully implemented. In the case of paracetamol overdose this has been included in the revised standard operating framework (appendix 3). The Trust adhere to national poisons guidance and access to this is available to all staff working in the ED/acute assessment areas.” Source location 2017-0270-Response-by-Medway-NSH-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 an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.
Verbatim wording from the response “2. As a result of this incident an algorithm has been written to add a ‘paracetamol to phone’ trigger test. Furthermore, on the first occurrence of an ALT level outside of the safe range (>825), the system flags a reminder to the laboratory staff to telephone it through to the requesting clinician. This flagging system was implemented on 5th September 2017 and applies to all tests were the levels are outside of the safe range and require immediate actions by a clinician. The Biochemistry Department “when to telephone a result” document is attached as appendix 5.” Source location 2017-0270-Response-by-Medway-NSH-Trust
Open published response
21 Nov 2016 Dennis Plater · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 6 Failure to understand the NEWS scoring system View source Insufficient testing and monitoring of agency staff compliance View source Incomplete fluid balance records View source Failure to apply the NEWS scoring system correctly View source Insufficient testing and monitoring of agency staff training, knowledge and understanding View source Failure to escalate a patient's condition when required 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
Dennis Plater · 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
Dennis Plater died of natural causes at Medway Maritime Hospital on 3 February 2016, following deterioration associated with acute kidney injury, sepsis and metastatic lung adenocarcinoma. The report identified incomplete fluid-balance records, failures in NEWS scoring and escalation by an agency nurse, and concerns about the Trust’s monitoring of agency staff training and compliance.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the NEWS scoring system
Wider context from the report “2) That a patient was placed in the care of Nurse who neither understood the NEWS scoring system , did not apply it correctly and failed to escalate patient's condition in circumstances where she ought to have done so.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient testing and monitoring of agency staff compliance
Wider context from the report “3)That the Trust did not have in place a sufficiently rigorous or effective system for testing and monitoring the training, knowledge, understanding and compliance of agency 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete fluid balance records
Wider context from the report “1) There were incomplete records kept and especially in respect of the fluid balance chart thereby rendering it an ineffective diagnostic tool .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the NEWS scoring system correctly
Wider context from the report “2) That a patient was placed in the care of Nurse who neither understood the NEWS scoring system, did not apply it correctly and failed to escalate patient's condition in circumstances where she ought to have done so.
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient testing and monitoring of agency staff training, knowledge and understanding
Wider context from the report “3)That the Trust did not have in place a sufficiently rigorous or effective system for testing and monitoring the training, knowledge, understanding and compliance of agency 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate a patient's condition when required
Wider context from the report “2) That a patient was placed in the care of Nurse who neither understood the NEWS scoring system, did not apply it correctly and failed to escalate patient's condition in circumstances where she ought to have done so .
” Open source report
16 May 2016 Jonathan Lewis Fry · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 5 Inconsistent or incomplete medical records View source Lack of senior Consultant review View source Lack of locum cover View source Failure to conduct daily review of test results View source Failure to consider unperformed tests and the reasons why View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jonathan Lewis Fry · 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
Jonathan Lewis Fry was admitted after an unwitnessed fall and was diagnosed with an L1 compression fracture. He later became increasingly unwell and was found unresponsive on 20 April 2015; the post-mortem cause of death was recorded as pulmonary embolism due to deep venous thrombosis. The principal concerns were the absence of senior Consultant review, inadequate follow-up of tests and results, and inconsistent or incomplete medical records.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent or incomplete medical records
Wider context from the report “3 ) Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of senior Consultant review
Wider context from the report “1) There was no Senior review by a Consultant from admission to the time of his death and was no locum cover
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of locum cover
Wider context from the report “1) There was no Senior review by a Consultant from admission to the time of his death and was no locum cover
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct daily review of test results
Wider context from the report “2 ) There was no daily review of test results and no consideration given to instances where tests had not been performed or consideration given to the reasons why
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider unperformed tests and the reasons why
Wider context from the report “2 ) There was no daily review of test results and no consideration given to instances where tests had not been performed or consideration given to the reasons why
” Open source report
23 Mar 2016 Alwyn Ann Head · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 5 Failure to record meaningful nursing information about dressing and wound condition View source Failure to establish MRSA history before surgery View source Failure to inspect the surgical wound View source Failure to provide prophylactic Teicoplanin when indicated by MRSA risk View source Failure to institute a post-operative wound care plan View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alwyn Ann Head · 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
Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record meaningful nursing information about dressing and wound condition
Wider context from the report “(5) Entries in the nursing notes relating to dressing and wound were meaningless and would not assist a determination of whether there was deterioration in the wound
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish MRSA history before surgery
Wider context from the report “(1) That Mrs Head had a history of MRSA was not established prior to surgery despite opportunities in 3 different hospital departments to obtain this information from Mrs. Head or her family
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inspect the surgical wound
Wider context from the report “(4) There was no evidence of the surgical wound having been inspected by nursing staff or doctors between the 13th August and 25th August 2015
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prophylactic Teicoplanin when indicated by MRSA risk
Wider context from the report “(2) Prophylactic Teicoplanin was not provided pre- or post-operatively even though the results of an MRSA screen would not have been available at the time of surgery (MRSA –ve written on pre-op form erroneously)
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to institute a post-operative wound care plan
Wider context from the report “(3) A post-operative wound care plan was not instituted contrary to NICE guidelines
” Open source report
17 Apr 2015 Robert Watt · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 7 Failure to explain the importance of haematuria clinic attendance View source Failure to obtain urological review when bladder malignancy is suspected View source Failure to communicate clinic cancellations to patients View source Failure to identify scheduled investigations before hospital discharge View source Failure to record clinic cancellations in medical records View source Lack of documentation of urology referrals and forward management of haematuria View source Failure to conduct renal or urological consultations through appropriately senior clinicians View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Robert Watt · 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
Robert Watt had suspected bladder cancer symptoms, including haematuria, weight loss and rectal bleeding, but investigations and specialist review did not identify the cancer until it was advanced and incurable. The report identified concerns about communication of a cancelled haematuria clinic appointment, incomplete medical records, reliance on junior doctors for specialist advice, and the lack of urological review when malignancy was suspected.
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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain the importance of haematuria clinic attendance
Wider context from the report “i. No party explained the importance of attendance at the haematuria clinic to Mr. Watt or his wife
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain urological review when bladder malignancy is suspected
Wider context from the report “v. A urologist was not asked to review Mr. Watt in circumstances where a malignancy was suspected and he was suffering from weight loss and haematuria both of which are recognised symptoms associated with bladder cancer
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clinic cancellations to patients
Wider context from the report “ii. The letter communicating the cancellation of the clinic was not sent to the deceased, nor was it placed on the medical records
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify scheduled investigations before hospital discharge
Wider context from the report “vi. The evidence has shown (although it does not relate to the death) that Mr. Watt was discharged from the hospital even though he was scheduled to have an OGD at the hospital on the date of discharge , which it appears that the physicians were unaware of .
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinic cancellations in medical records
Wider context from the report “ii. The letter communicating the cancellation of the clinic was not sent to the deceased, nor was it placed on the medical records
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of urology referrals and forward management of haematuria
Wider context from the report “iii. There is no documentation relating to the referral to urology and forward management of haematuria within the medical records
” 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 Medway NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct renal or urological consultations through appropriately senior clinicians
Wider context from the report “iv. On each occasion that he medical team consulted with renal or urological physicians in seeking advice how to manage their patient, the consultation was conducted through the most junior doctor on the ward (FY1)
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations