Recipient

Mid Staffordshire NHS Foundation Trust

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First report 6 Feb 2014•Latest report 6 Feb 2014

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
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Mid Staffordshire NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Staffordshire South

    AI-generated summary

    Ethel Smith Leese · 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

    Ethel Smith Leese, aged 94, was admitted to hospital after a fall at her care home on 1 January 2013 and died on 4 January 2013. The inquest concluded that her death was accidental, involving intracerebral and subdural haemorrhage, a fall, warfarin-induced coagulopathy, and other listed conditions. The principal concern was chaotic monitoring arrangements for her warfarin levels, including uncertainty and errors concerning her address and GP practice after she moved to the care home.

    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 Mid Staffordshire NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate patient address and GP practice details

    Wider context from the report

    “(1) There was one matter of concern which relates to the monitoring of Mrs Leese’s warfarin levels. The move to the care home required Mrs Leese to be changed to a different GP practice. The checking by the hospital of Mrs Leese’s address (including the address for posting for the yellow booklet) appears to have been fairly chaotic. Her address on the paperwork seems to have remained unchanged, there appears to have been doubt as to whether Cumberland House Medical Practice in Stone or the Penkridge Medical Practice (covering Dunston) were her GPs practice and indeed on one occasion information was sent to the wrong GP practice in Stone (Mansion House). It may be that Mrs Leese was initially considered to be a temporary resident at the care home in Dunston but I wonder if there is a possibility to record addresses better. Possibly this may not just apply in the Haematology Department but in the hospital as a whole. Whilst this may not have been directly relevant in this case it could be significant in other deaths. ”
    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

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

How actions were described at the time

This respondent
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