Recipient

Mersey and West Lancashire Teaching Hospitals NHS Trust

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First report 3 Mar 2021•Latest report 9 May 2021

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
13

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

50%published responses found
13stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Mersey and West Lancashire Teaching Hospitals NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to Southport and Ormskirk Hospital NHS Trust, now represented here by Mersey and West Lancashire Teaching Hospitals NHS Trust.

    Liverpool and the Wirral

    AI-generated summary

    Eva Hayden · 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

    Eva Hayden, aged four, developed neutropenia following an illness and later became seriously unwell with fever-like symptoms. She collapsed on 10 January 2020 and died in the emergency department on 11 January 2020; the inquest found sepsis and bone marrow hypoplasia. Concerns included missed follow-up of her neutropenia, inadequate communication between hospitals, and insufficient communication with her parents about infection risks.

    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 Mersey and West Lancashire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate treatment plans and condition-related risks to patients and confirm their understanding

    Wider context from the report

    “a) When investigating, diagnosing or treating a patient’s presentation it seems reasonable that there should be good communication between clinician and patient with regard to the treatment plan. Understanding of the patient should be confirmed with regard to any precautions or risks arising from the condition. In this matter, Eva’s parents had no knowledge of the pancytopenia or neutropenia under investigation and the risks of infection for Eva – such that this was not explained to the staff in the Emergency department at Alder Hey on 8th January 2020. Clinical practice should have prevented this eventuality. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mersey and West Lancashire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of clinical communication between Trusts about unresolved investigations

    Wider context from the report

    “b) When Eva missed the appointment at Ormskirk Hospital on the 25th November 2019 for her blood tests – there was no follow up by the hospital as there was an “assumption” that a follow-up orthopaedic appointment for cellulitis would investigate her neutropenia. The assumption was wrong and there was no clinical communication between the Trusts, which would have clarified that investigation of neutropenia had ceased without resolution. The onus for investigations cannot be on a four year old or her parents who were unaware of the potentially fatal implications. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mersey and West Lancashire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow up missed appointments for investigation of neutropenia

    Wider context from the report

    “b) When Eva missed the appointment at Ormskirk Hospital on the 25th November 2019 for her blood tests – there was no follow up by the hospital as there was an “assumption” that a follow-up orthopaedic appointment for cellulitis would investigate her neutropenia. The assumption was wrong and there was no clinical communication between the Trusts, which would have clarified that investigation of neutropenia had ceased without resolution. The onus for investigations cannot be on a four year old or her parents who were unaware of the potentially fatal implications. ”
    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

    Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.

    Verbatim wording from the response

    “6. We are confident that the implementation of the actions described in points 3 and 5 above will ensure that there is a clear response each time a child is not brought to an appointment and we have introduced a routine audit to be undertaken every month to measure that our updated policy and processes are being adhered to. This will be monitored through speciality and CBU governance arrangements with any breaches against the policy being escalated through the Trust incident management processes.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 2 · response
    Published 18 May 2021

    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 communication documentation and the quality of recorded clinical information through a routine audit cycle.

    Verbatim wording from the response

    “clinic letters to parents. This will be followed up through a routine cycle of audits which will commence in July 2021 to ensure adherence to this directive and additionally to assess the quality of clinical information that is being recorded. We are working closely with Alder Hey team to ensure that families transferred from Alder Hey to Ormskirk for ongoing investigations have an understanding of the reasons and plans.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 2 · response
    Published 18 May 2021

    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 consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.

    Verbatim wording from the response

    “3. The Trust immediately implemented safeguards to prevent a similar incident occurring when a child is not brought to a scheduled outpatient or ward attender appointment. All non-attendances are sent to the Consultant in charge of the care to clinically review and agree on what course of action needs to be taken. Examples of further actions could include, another appointment being offered or a discussion with another Trust if there are shared care arrangements. In all cases there will be documented evidence of the follow-up action that has taken place, e.g. letter to GP and/or parents.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 2 · response
    Published 18 May 2021

    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

    Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.

    Verbatim wording from the response

    “1. At the time of this event there were paper-based systems in use, this has now changed and ward attender appointments are now scheduled on Medway (PAS) and clinically annotated at the time of the attendance. This ensures that patients are tracked and diarised electronically with outcomes recorded on the patient system.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 1 · response
    Published 18 May 2021

    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

    Re-emphasise communication with families and documentation of discussions through clinical-team meetings and regular communications, including providing relevant letters.

    Verbatim wording from the response

    “2. The importance of ensuring clear communication with parents and/or children about conditions that are being investigated and the documentation of these conversations in the case note or electronic system has been re-emphasised to all clinical teams through staff meetings and regular communications. We provide copies of discharge letters and outpatient department”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 1 · response
    Published 18 May 2021

    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 standardised communication and referral processes with Alder Hey and the wider paediatric network, particularly for shared-care arrangements.

    Verbatim wording from the response

    “clinic letters to parents. This will be followed up through a routine cycle of audits which will commence in July 2021 to ensure adherence to this directive and additionally to assess the quality of clinical information that is being recorded. We are working closely with Alder Hey team to ensure that families transferred from Alder Hey to Ormskirk for ongoing investigations have an understanding of the reasons and plans.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 2 · response
    Published 18 May 2021

    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 the outpatient non-attendance pathway and review cases where children were not clinically reviewed.

    Verbatim wording from the response

    “4. We have completed a full audit exercise to look at the pathway and scenario that Eva was under as she was those patients that attend through a standard outpatient appointment. Whilst this identified that in the majority of cases, the existing DNA Policy and processes were followed; there were 5 occasions where a patient didn’t attend an outpatient appointment and wasn’t clinically reviewed. Each incidence has been reviewed and there were no incidents of harm identified as a result.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 2 · response
    Published 18 May 2021

    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

    Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.

    Verbatim wording from the response

    “5. We have reviewed our ‘Did Not Attend (DNA)’ Policy to reflect the requirements of the Regulation 28 report and ensure that any necessary safeguards from the work described above are contained within the policy. The Policy has also been re-vamped to ensure it reflects best practice and principles that a child ‘Was Not Brought’ as opposed to DNA. The updated policy is due to be presented at the clinical business unit (CBU) governance meeting on 08/07/2021 and will be subject to the governance arrangements of the Trust. The Was Not Brought Policy is a corporate Policy and will apply to all children anywhere within the trust.”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 2 · response
    Published 18 May 2021

    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

    Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.

    Verbatim wording from the response

    “10. The circumstances and details of this case have been widely shared. In addition, we are amending the local induction for staff in paediatrics to ensure that staff are provided with important information about the requirements of:”

    Source location

    2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
    Page 3 · response
    Published 18 May 2021

    Open published response

  2. Liverpool and the Wirral

    AI-generated summary

    Helen Margaret McLean · 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

    Helen Margaret McLean was without Edoxaban from 5 November 2020 after medication and discharge information were not correctly transferred between hospital, GP practices and her nursing home. She was admitted to hospital with an ischaemic stroke on 18 November 2020 and died on 21 November 2020; the report found it more likely than not that Edoxaban may have prevented the fatal event. A substantive concern was that the discharge summary was not received by the GP practice and contained an incorrect GP practice identifier, with medication-transfer processes also failing to identify the omission.

    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 Mersey and West Lancashire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to transmit discharge summaries to GP practices

    Wider context from the report

    “Following admission to Whiston Hospital on 12ᵗʰ August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong. (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mersey and West Lancashire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record the correct GP practice name and identifier on discharge summaries

    Wider context from the report

    “Following admission to Whiston Hospital on 12ᵗʰ August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong. (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

50%
50%All other recipients 58%
0%100%

How actions were described at the time

This respondent
46%31%23%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026