Concerns raised 3 Failure to communicate treatment plans and condition-related risks to patients and confirm their understanding View source Failure of clinical communication between Trusts about unresolved investigations View source Failure to follow up missed appointments for investigation of neutropenia View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
View source
Action
Audit communication documentation and the quality of recorded clinical information through a routine audit cycle.
View source
Action
Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
View source
Action
Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
View source
Action
Re-emphasise communication with families and documentation of discussions through clinical-team meetings and regular communications, including providing relevant letters.
View source
Action
Develop standardised communication and referral processes with Alder Hey and the wider paediatric network, particularly for shared-care arrangements.
View source
Action
Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
View source
Action
Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
View source
Action
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
View source See 6 more actions
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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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit 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
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 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
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 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
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 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
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 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit 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
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 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend 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
Open published response
3 Mar 2021 Helen Margaret McLean · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Failure to transmit discharge summaries to GP practices View source Failure to record the correct GP practice name and identifier on discharge summaries View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
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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Request correction
Addressed to Southport and Ormskirk Hospital NHS Trust, now represented here by Mersey and West Lancashire Teaching Hospitals NHS Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations