31 Mar 2026 Raisa Cristina Iordan · Prevention of Future Deaths report West Yorkshire Western
View report summary
Concerns raised 5 Failure to provide adequate clinical assessment View source Delays in obtaining scans due to insufficient on-call staffing View source Lack of trained support for paediatric emergency intubation View source Lack of paediatric radiology expertise in out-of-hours imaging interpretation View source Failure to consider concerns raised by other clinicians View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raisa Cristina Iordan · 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
Raisa Cristina Iordan became less responsive and developed seizures and severe neurological symptoms after returning to Dewsbury District Hospital with a suspected viral illness. She was later transferred to Sheffield Children’s Hospital, where imaging showed catastrophic and irreversible brain herniation, and her death was confirmed on 30 November 2023. Concerns included missed escalation of care, inaccurate interpretation of imaging by an external general radiologist without paediatric radiology experience, and delays in scanning and intubation.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate clinical assessment
Wider context from the report “1) Concerns were raised by a Junior Doctor in respect of Raisa's presenting symptoms, which were ignored by the more Senior Doctor in charge, whose assessment of Raisa was limited and of poor quality . The more Senior Doctor formed a view that Raisa was experiencing febrile convulsions and they were unwilling to consider the views, observations or concerns raised by not only the Junior Doctor but by other clinicians who had been caring for Raisa during the course of her admission.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining scans due to insufficient on-call staffing
Wider context from the report “3) There were delays in obtaining a scan for Raisa as there was only one on call anaesthetist at Dewsbury and one on call radiographer . The scan was required prior to Raisa being transferred as the treating clinicians needed to ensure that not only was it safe for Raisa to be transferred but also that she was being transferred to a hospital that was able to provide appropriate care, there being no paediatric intensive care unit at Pinderfields 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of trained support for paediatric emergency intubation
Wider context from the report “4) There were delays in Raisa being intubated as there was no support for the on call anaesthetist , with no Operating Department Practitioner or other trained member of staff to help manage a critically ill paediatric patient .
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric radiology expertise in out-of-hours imaging interpretation
Wider context from the report “2) Since September 2021, the standard practice across the Mid Yorkshire Teaching NHS Trust has been that the interpretation of out of hours radiology is provided by an external agency, Telemedicine Clinic Limited ("TMC"). The company provides radiology reporting services to a large number of hospitals, providing, amongst other things, acute on call radiology reporting services. Although TMC has a number of radiologists available from a variety of subspecialties to provide reports, their expertise are limited to that of adult radiology, rather than paediatric radiology . At the time the scan was undertaken, the radiographer raised concerns that the imaging appeared abnormal and contacted TMC to ensure that no further imaging was required and in the course of that conversation, concerns were raised in respect of raised intracranial pressure. When the images were reported by TMC, it was said that there was no convincing evidence of acute intracranial pathology , but when Raisa's imaging was reviewed at Sheffield Children's Hospital, it was noted that there was obvious brain herniation which had not been identified by the general radiologist at TMC .
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider concerns raised by other clinicians
Wider context from the report “1) Concerns were raised by a Junior Doctor in respect of Raisa's presenting symptoms, which were ignored by the more Senior Doctor in charge , whose assessment of Raisa was limited and of poor quality. The more Senior Doctor formed a view that Raisa was experiencing febrile convulsions and they were unwilling to consider the views, observations or concerns raised by not only the Junior Doctor but by other clinicians who had been caring for Raisa during the course of her admission .
” 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 regular multidisciplinary simulation training for escalation, communication, deterioration management and paediatric airway scenarios.
Verbatim wording from the response “• Implementation of regular multidisciplinary simulation training focused on escalation, communication and management of deteriorating paediatric patients” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce clinician-to-radiologist communication processes for complex cases and maintain audit and peer review of radiology reports.
Verbatim wording from the response “• Ongoing audit and peer review of radiology reporting, including externally provided reports.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approve a business case for a dedicated DDH anaesthetic consultant on-call rota.
Verbatim wording from the response “Out-of-hours anaesthetic provision has been identified as a critical dependency in the management of deteriorating children, and the following actions have been taken:” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the out-of-hours deteriorating-child procedure with clearer escalation triggers and senior-review requirements.
Verbatim wording from the response “1. Escalation of Clinical Concerns
The Trust accepts the concern that clinical observations and concerns raised by junior and other clinicians were not escalated or acted upon appropriately.
In response, the Trust has implemented the following measures:” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce professional expectations for escalating concerns and clinically challenging decisions, including disagreements.
Verbatim wording from the response “• Reinforcement of professional expectations regarding escalation of concerns and clinical challenge, including in situations of disagreement” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the dedicated anaesthetic rota following recruitment.
Verbatim wording from the response “Further actions include implementation of the anaesthetic rota, subject to recruitment.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a monthly multidisciplinary deteriorating-patient governance group to review cases and escalation performance.
Verbatim wording from the response “• Establishment of a monthly Deteriorating Patient Governance Group to review cases and escalation performance” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit escalation-process compliance through established governance arrangements.
Verbatim wording from the response “Compliance with escalation processes is subject to ongoing audit through established governance structures.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress towards an on-site overnight radiographer model while monitoring response times and prioritisation of critically unwell patients.
Verbatim wording from the response “Further work is in progress to move towards an on-site overnight radiographer model, subject to workforce availability, alongside continued monitoring of response times and prioritisation of critically unwell patients.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit overnight CT response times and review the workforce model supporting CT provision at DDH.
Verbatim wording from the response “Actions undertaken include:” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an enhanced out-of-hours paediatric rapid-response model through ongoing recruitment.
Verbatim wording from the response “Further actions include the introduction of an enhanced out-of-hours paediatric rapid response model, for which recruitment is currently underway.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Median overnight CT request-to-scan times are comparable with other Trust sites, although time-critical delays still require mitigation.
Verbatim wording from the response “3. Delays in CT Imaging
The Trust acknowledges the concern regarding delays in obtaining CT imaging. An audit of overnight CT activity indicates that median time from request to scan is comparable to other Trust sites. However, the Trust recognises that delays in time-critical cases require continued mitigation.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine overnight access to subspecialist paediatric radiology reporting is unavailable within West Yorkshire.
Verbatim wording from the response “with over 50 UK hospitals. Its radiologists are all trained to the same standard as NHS consultant radiologists, with equivalent qualifications, and their reporting quality is audited, with a minimum of 5% of their reports peer-reviewed. Routine access to subspecialist paediatric radiology reporting overnight is not available within West Yorkshire. The Trust is aware that TMC have also been sent the regulation 28 and will issue a response.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementing the dedicated out-of-hours anaesthetic consultant rota is subject to recruitment.
Verbatim wording from the response “Further actions include implementation of the anaesthetic rota, subject to recruitment.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Moving to an on-site overnight radiographer model is subject to workforce availability.
Verbatim wording from the response “Further work is in progress to move towards an on-site overnight radiographer model, subject to workforce availability, alongside continued monitoring of response times and prioritisation of critically unwell patients.” Source location Response from Mid Yorkshire Teaching Hospital NHS Trust
Open published response
1 Dec 2023 Ms Samantha Jade Shillito · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Unavailability of relevant specialist consultants in hospital View source Failure to communicate the seriousness and potential mortality of a patient's condition to family View source Failure to provide adequately informed consent for ascitic tap procedures View source Failure to escalate, assess and investigate NEWS-triggered deterioration View source Lack of quantified published evidence on ascitic tap risks View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Samantha Jade Shillito · 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
Ms Samantha Jade Shillito was significantly unwell when admitted to hospital and underwent an ascitic tap procedure that perforated an artery, causing intra-abdominal bleeding. She deteriorated over the following weekend without medical review or further investigations and died on 27 February 2022. Concerns included missed opportunities to respond to her deterioration, inadequate information about the risks of the procedure and shortcomings in communication with her family.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant specialist consultants in hospital
Wider context from the report “(1) There were no relevant specialist consultants in the hospital on the night of Friday 25/2/22, during Saturday 26/2/22 or on Sunday 27/2/22. Ms Shillito had a NEWS score which should have triggered an escalation of her treatment, but she was neither reviewed, examined properly or subjected to further investigations (such as blood tests and/or a CT scan) to establish the cause of her deterioration. Evidence was heard at the inquest from a consultant hepatologist to the effect that this was a missed opportunity to initiate remedial action when her deterioration could have been halted and her condition improved.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the seriousness and potential mortality of a patient's condition to family
Wider context from the report “(4) Ms Shillito’s family were not made aware of the seriousness of her underlying illness. No effective communication was provided to them even on Sunday 27 February to help them appreciate the gravity of her situation. Her husband and her mother informed the inquest that they had not been told that she might die. In consequence, the shock of her death on the evening of Sunday 27 February 2022 was all the greater. It is acknowledged that this concern did not contribute to Ms Shillito’s death, but it underlines the need for compassion and candour when dealing with patients and their families.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequately informed consent for ascitic tap procedures
Wider context from the report “(3) The practice at the hospital was to obtain verbal consent to the procedure from the patient in the minutes before it took place. A consultant radiologist acknowledged that the risk of death was not mentioned to Ms Shillito. It is questionable whether this can be considered to be a patient’s informed consent when the risks outlined are not reliably established, are not explained and the patient is not asked to sign a document. If there is a risk of death, irrespective of its rarity, the patient is entitled to be informed. This concern is heightened when one considers the patient’s medical condition and their likely emotional state, in circumstances which allow no time for reflection or discussion with other family members. It appears that no leaflet describing the ascitic tap procedure and the associated risks has been provided either by the Royal College of Radiologists or the 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate, assess and investigate NEWS-triggered deterioration
Wider context from the report “(1) There were no relevant specialist consultants in the hospital on the night of Friday 25/2/22, during Saturday 26/2/22 or on Sunday 27/2/22. Ms Shillito had a NEWS score which should have triggered an escalation of her treatment, but she was neither reviewed, examined properly or subjected to further investigations (such as blood tests and/or a CT scan) to establish the cause of her deterioration. Evidence was heard at the inquest from a consultant hepatologist to the effect that this was a missed opportunity to initiate remedial action when her deterioration could have been halted and her condition improved.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of quantified published evidence on ascitic tap risks
Wider context from the report “(2) The ascitic tap procedure was said to be commonly undertaken and was regarded as low risk. The inquest was, however, unable to establish the magnitude of the risks of bleeding, infection or perforation of surrounding structures by reference to the medical literature or statistical evidence. How then can it be said to be a low-risk procedure if the inherent risks have not been quantified? This was viewed as a national (if not an international) problem, which requires published evidence to inform radiological practice.
” 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 Promote and embed compassionate, inclusive communication with patients and their families.
Verbatim wording from the response “I fully recognise the requirement for compassion and candour with patients and families as part of their medical care experience. I am sorry that our communications with Ms Shillito’s family fell below the high standard we strive to achieve, and that they were entitled to expect. The Trust has wholeheartedly embraced the NHS's changed methodology for investigating patient incidents / events through the new national Patient Safety Incident Response Framework (PSIRF), where patients and families have a greater voice and involvement. Aligned with this philosophy, the Trust is actively promoting a more compassionate and inclusive approach by staff/clinicians in all communications with patients and their families.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting clinicians and patients to assess and discuss ascitic-tap risks and benefits before procedures.
Verbatim wording from the response “Therefore to address this concern fully, we welcome any advice from the Royal College of Radiologists (also issued with this regulation 28). In the interim, however, we continue to work with our clinical teams to support appropriate risk/benefit assessments by the healthcare professional and consideration of these risks/benefits with patients prior to a procedure.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ongoing deterioration-response education to nursing, allied health and junior medical staff.
Verbatim wording from the response “The Trust also has escalation protocols in place to recognise when a patient’s condition deteriorates, with appropriate response pathways prescribed. However, we know these protocols require regular review to be assured they are fit for purpose and are continually improved locally, and across the NHS. We undertake ongoing education with our teams of nursing, allied health professions (AHP) staff, and junior doctors so that when deterioration of patients occur, they promptly receive correct specialist input and treatment.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Augment the deteriorating-patient response service with additional capacity.
Verbatim wording from the response “We have augmented this service and also launched the Call 4 Concern patient safety initiative (based on Martha’s rule). This enables a patient or family member to seek help or advice if a patient’s condition deteriorates. A new phone number is publicised on wards which connects to members of DART for a response. Patients and family members can call for help or advice if:” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review patient-safety leaflets against relevant professional guidance to support informed shared decisions about ascitic-tap care.
Verbatim wording from the response “With regard to patient information leaflets, we do use patient information leaflets for many procedures but not universally for those procedures that are perceived to be very low risk. I acknowledge that in my own exploration of this concern I have identified several NHS Trusts which have information leaflets for a diagnostic ascitic tap procedure (needle removal of a small amount of fluid) and/or the more invasive paracentesis (usually implied as insertion of a drain to remove larger volumes of fluid). None of those leaflets specifically mention the risk of death. We will, however, review our patient safety leaflets in accordance with relevant guidance from professional bodies such as the Royal College of Radiologists and British Society of Interventional Radiology to” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a 24/7 Deteriorating Adult Response Team for patients meeting deterioration referral criteria.
Verbatim wording from the response “In addition we have recently introduced the Deteriorating Adult Response Team (DART) previously called the Critical Care Outreach Team (CCOT) as a 24/7 service. This multi professional team provides an initial response when patients with deteriorating NEWS are identified. Guidance for referral includes a NEWS of 7 or more, an increasing oxygen requirement of above 40%, or if there are any concerns about a patient deteriorating (irrespective of their NEWS / oxygen requirement).” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Call 4 Concern patient-safety initiative, connecting ward calls from patients or families to Deteriorating Adult Response Team members.
Verbatim wording from the response “We have augmented this service and also launched the Call 4 Concern patient safety initiative (based on Martha’s rule). This enables a patient or family member to seek help or advice if a patient’s condition deteriorates. A new phone number is publicised on wards which connects to members of DART for a response. Patients and family members can call for help or advice if:” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and improve escalation protocols for recognising and responding to deteriorating patients.
Verbatim wording from the response “The Trust also has escalation protocols in place to recognise when a patient’s condition deteriorates, with appropriate response pathways prescribed. However, we know these protocols require regular review to be assured they are fit for purpose and are continually improved locally, and across the NHS. We undertake ongoing education with our teams of nursing, allied health professions (AHP) staff, and junior doctors so that when deterioration of patients occur, they promptly receive correct specialist input and treatment.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Verbal consent remains acceptable for many low-risk procedures because written consent is impracticable in every instance; patient leaflets are not universal.
Verbatim wording from the response “As you are aware, the process of consenting a patient for a procedure is an ongoing one that starts with a conversation with the patient about treatment options and culminates with the signing of the consent form. The form itself is merely the final “ok” from the patient to go ahead after a number of steps have taken place over a length of time, to obtain fully informed consent from the patient.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot definitively quantify ascitic tap risks because specific published evidence is absent, a national or international problem.
Verbatim wording from the response “As an organisation that provides healthcare, we rely on various sources of information to enable us to quantify the risks of any procedure. The majority of this information is sourced from guidance issued by specialist societies, royal colleges, or developed through literature evidence base/local audits etc. In the instance where there is an absence of specific quantifiable risks, best practice is to inform patients of potential complications with indicative likelihoods of these occurring. For an ascitic tap it is felt to be very low risk based on the experience and judgement of the health professionals involved. Decisions to proceed with an intervention would also be balanced against the risk of not proceeding with an intervention” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that no relevant specialist consultants were available, stating at least 25 consultants are present onsite during weekends.
Verbatim wording from the response “Specialist consultants are always available to be contacted out of hours and weekends if needed to provide advice and support for other clinical staff or to return directly to the hospital within a short time period if required. At any given time there are therefore varying numbers of specialists within the hospital grounds. Across specialties a minimum of 25 Consultants are present during weekends. Some specialties do have a fixed onsite 24/7 presence during and others provide an on call service with expectations of a direct return to site if needed within a maximum of 30 minutes.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
8 Jun 2023 David Barnet WILSON · Prevention of Future Deaths report West Yorkshire (Eastern)
View report summary
Concerns raised 5 Failure to provide statistical ratings for identified procedural risks View source Failure to communicate the risk of death in the consent form View source Obtaining consent signatures while patients are under morphine sedation View source Failure to identify clinicians involved in consent discussions View source Failure to tailor procedural risks to the patient's medical history and co-morbidities View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Barnet WILSON · 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
David Barnet Wilson was admitted to hospital with suspected colitis and underwent a flexible sigmoidoscopy, during which a recognised colonic perforation occurred. He died at Pinderfields Hospital on 31 December 2022; concerns included inadequate explanation and tailoring of procedural risks, failure to mention the risk of death, and obtaining consent while he was under morphine sedation.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide statistical ratings for identified procedural risks
Wider context from the report “(1) The Consent form signed by Mr Wilson was a standard pre-printed form. It did not attempt to provide any statistical rating for the risks identified , which would have enabled Mr Wilson to evaluate the risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the risk of death in the consent form
Wider context from the report “(3) The Consent Form did not refer to the risks of death , which befell him. He was thus not in a position to make a truly informed consent to undergo the sigmoidoscopy.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Obtaining consent signatures while patients are under morphine sedation
Wider context from the report “(4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for ████████ who obtained his signature at a time when he was under the influence of morphine sedation .
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify clinicians involved in consent discussions
Wider context from the report “(4) The Consent Form did not identify those clinicians involved in discussing the decision with him , save for ████████ who obtained his signature at a time when he was under the influence of morphine sedation.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to tailor procedural risks to the patient's medical history and co-morbidities
Wider context from the report “(2) No attempt was made to interpret or tailor the risks inherent in the procedure in the light of his extensive medical history and co-morbidities.
” 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 procedure-specific consent forms to include statistical frequency ranges for identified risks as each form undergoes review.
Verbatim wording from the response “The Trust utilises a bank of consent forms for the most common procedures performed. The consent forms used in MYTT are based on national guidance issued by the Department of Health and Social Care. Of note, we currently have generic forms and hundreds of procedure-specific consent forms across all specialties. The procedure-specific consent forms are pre-populated with the most frequently associated risks for the particular procedure. The forms are reviewed and amended as required to align with contemporary medical knowledge and practice.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with clinical teams to ensure patients’ capacity to consent is considered, taken into account, and properly documented.
Verbatim wording from the response “In relation to the capacity to consent, the Trust will work with clinical teams to ensure that as part of the consent process, the question of a patient’s capacity – regardless of the circumstances – is considered, taken into account, and properly documented. The issues surrounding capacity will also be further highlighted in the Trust’s internal policy (see below).” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh the consent policy to require documentation of patient-specific increased risks, earlier discussion of death risk, and consideration and documentation of capacity.
Verbatim wording from the response “As it is proposed to include risk ranges, to a certain degree these will inherently account for varying medical histories and co-morbidities of patients. But in instances where a specific risk is greater due to a particular patient’s unique circumstances, this medical advice will be clearly noted. We will also update and strengthen our consent process through our internal policy to reflect this requirement (see below).” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce death as a specific risk that clinicians must canvass during the consent process.
Verbatim wording from the response “The Trust also appreciates that the risk of death is a possibility in every procedure that is undertaken, and that even if it is a remote possibility, the risk of death would be a material consideration for patients in assessing whether to go ahead with a procedure.²” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Time and resource constraints make listing all staff involved throughout a patient's consent process impracticable.
Verbatim wording from the response “Ideally the final consent form would list all MYTT staff who have been involved throughout the entire consenting process of the patient for a particular procedure. Unfortunately, time and resource constraints make this suggestion impracticable for implementation by the Trust.” Source location Response from Mid Yorkshire Teaching NHS Trust
Open published response
29 Sep 2021 Mary Land · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Use of a mask-to-tubing push-on connection vulnerable to coming apart View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Land · 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
Mary Land, aged 76, was being treated for COVID pneumonia when she was found unresponsive with the tubing connecting her facemask to a BIPAP ventilator detached. The Inquest could not determine whether the detachment contributed to her death, but identified concern that the push-on connection could come undone and may require a more robust docking mechanism.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of a mask-to-tubing push-on connection vulnerable to coming apart
Wider context from the report “The Philips Respironics AF 541 mask connects to the tubing, linking it to the BIPAP ventilator by means of a ‘push on’ connection (rather than a fitting involving positive engagement) . Evidence taken at the Inquest indicates this connection has come undone on other occasions as well . The introduction of a filter at the site of this union increases the potential for the joint to come apart . Consideration should be given to installing a more robust docking mechanism which is less vulnerable to working loose, or being inadvertently pulled apart , for example, by a patient suffering from delirium.
” 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 Investigate manufacturer or other solutions and discuss with regional units how to improve tubing-circuit connection stability.
Verbatim wording from the response “Recommendation 2: Scope and discuss with regional units if there can be an improvement on securing tubing circuit connections” Source location 2021-0322-Response-from-Mid-Yorkshire-Hospitals_Published-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss filter use and its effect on circuit stability with the Respiratory Team and non-invasive ventilation lead.
Verbatim wording from the response “Unfortunately, the additional filter component inserted between the facemask and the ventilator tubing may have contributed to destabilisation of the circuit, although this cannot be clinically proven, and there is no current research/evidence to confirm or reject the theory that the additional filter caused/causes destabilisation of the circuit.” Source location 2021-0322-Response-from-Mid-Yorkshire-Hospitals_Published-1
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 When design solutions were researched, no all-in-one circuit integrating the filter into the mask was available.
Verbatim wording from the response “Of note, at the time when the incident was investigated and design solutions were researched, there was no all-in-one circuit available, i.e. where the filter was an integral constituent of the mask, rather than an optional add-on component. As such, the Trust thanks you for raising this issue directly with the manufacturer, Philips Respironics.” Source location 2021-0322-Response-from-Mid-Yorkshire-Hospitals_Published-1
Open published response
Concerns raised 4 Failure to adhere to the hospital discharge protocol for self-discharge View source Failure to notify the intensive home-based treatment team of a patient's self-discharge View source Failure to assess and provide treatment by the in-house psychiatric team View source Delays in seeking updates from the hospital about a patient View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Denton Donovan DUHANEY · 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
Denton Donovan Duhaney was admitted to hospital with physical and mental health concerns and was assessed as being at high risk of further mental health deterioration. He self-discharged without assessment by the hospital’s in-house psychiatric team or notification to the community treatment team, and was found dead at home several days later; the recorded cause of death was hanging (asphyxia), with a conclusion of suicide. The substantive concerns included failures in psychiatric assessment, discharge protocol, communication about the self-discharge, and follow-up arrangements.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the hospital discharge protocol for self-discharge
Wider context from the report “2. Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr Duhaney expressed a wish to self-discharge.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the intensive home-based treatment team of a patient's self-discharge
Wider context from the report “3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge .
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and provide treatment by the in-house psychiatric team
Wider context from the report “1. Mr Duhaney was a patient at Pinderfield’s Hospital between 23rd and 25th June but at no time was he assessed or receive treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking updates from the hospital about a patient
Wider context from the report “4. Kirklees Home Based Treatment Team last had contact with Pinderfield’s Hospital on 24th June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr Duhaney.
” Open source report
10 Nov 2020 Leslie Clewarth · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to account for unused drugs View source Lack of adequate records documenting care provided and dosages administered View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie Clewarth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leslie Clewarth died in hospital from natural causes, with the Inquest recording aspiration pneumonia, small bowel obstruction, adhesions within the peritoneal cavity, and ischaemic heart disease. Concerns included the loss of his NG tube, an empty syringe driver, an injection administered after death, lack of treatment for a severe coronary condition, and missing or inadequate medical records. The principal substantive concern was that inadequate records made it impossible to corroborate the care and medication provided and created a risk that essential care could be omitted or duplicated.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for unused drugs
Wider context from the report “(1) Without adequate records showing the care provided or dosage administered, it was not possible to corroborate the testimony of nurses who had attended to Mr Clewarth on the afternoon he died. This fuelled the suspicions raised by his daughter and her husband.
(2) Drugs which were left unused after Mr Clewarth’s death were not accounted for .
Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient's safety or health at risk.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate records documenting care provided and dosages administered
Wider context from the report “(1) Without adequate records showing the care provided or dosage administered , it was not possible to corroborate the testimony of nurses who had attended to Mr Clewarth on the afternoon he died. This fuelled the suspicions raised by his daughter and her husband.
(2) Drugs which were left unused after Mr Clewarth’s death were not accounted for.
Without proper records there is a risk that essential care may not be provided or is erroneously duplicated , thus potentially putting a patient's safety or health at risk.
” 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 Revise the syringe pump policy and prescription/administration chart to clarify recording of residual and discarded medication and prompt timely syringe changes.
Verbatim wording from the response “In light of the above reviews we have determined that the syringe pump policy and the prescription / administration chart should be revised to provide clearer guidance and support adherence to the policy. In particular this relates to the recording of any medication remaining in the syringe at each check and the amount discarded at the change or end of the use of the syringe driver and a prompt to support staff in recognising when the next syringe change will be required. Once the revised policies have gone through the appropriate governance routes in the Trust there will be further training delivered to support their use.” Source location 2020-0229-Response-from-Mid-Yorkshire-Hospitals-NHS-Trust-1.pdf
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 further training to support use of the revised syringe pump policy and prescription/administration chart after governance approval.
Verbatim wording from the response “In light of the above reviews we have determined that the syringe pump policy and the prescription / administration chart should be revised to provide clearer guidance and support adherence to the policy. In particular this relates to the recording of any medication remaining in the syringe at each check and the amount discarded at the change or end of the use of the syringe driver and a prompt to support staff in recognising when the next syringe change will be required. Once the revised policies have gone through the appropriate governance routes in the Trust there will be further training delivered to support their use.” Source location 2020-0229-Response-from-Mid-Yorkshire-Hospitals-NHS-Trust-1.pdf
Open published response
4 Apr 2019 Mr Alfred Howell · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Delays in reporting CT scans within the Trust’s five-day timescale View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Alfred Howell · 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
Mr Alfred Howell was admitted to hospital after respiratory deterioration, including bilateral pleural effusions and partial lung collapse. His condition deteriorated, and he suffered a cardiac arrest and died on 5 June 2018. The principal concern was that CT scans took 14 and 12 days to be reported, exceeding the Trust’s five-day target, although the inquest evidence did not indicate that the delays contributed to his death.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting CT scans within the Trust’s five-day timescale
Wider context from the report “During investigations into Mr Howell’s medical condition, CT scans were taken on a number of occasions.
Specifically, he underwent a CT scan on 24th March 2018 which was reported on by the radiology department on 7th April 2018. Upon review at an MDT on 17th April 2018, a deterioration of the changes previously seen in both lungs was noted. An MDT plan was then to perform an early follow up CT to assess whether the changes might prove given that he had further antibiotic treatment for infection.
The repeat scan took place on 17th May 2018 and was reported by the outsource company TMC on 29th May 2018. At that stage the scan was abnormal and significantly deteriorated and was brought to the attention of the Consultant in Respiratory and General Medicine. There had been an increase in the areas of consolidation, an increase in the size of now bilateral pleural effusions and both lungs had collapsed slightly. The Consultant took immediate steps to facilitate Mr Howell’s admission to hospital.
The Consultant who provided evidence at the Inquest commented that a period of 5 days from CT scan to reporting by radiology is the timescale target within the Trust.
The aforesaid scans took 14 days and 12 days to be reported on respectively. The latter scan was brought to the Consultant’s attention immediately.
Mr Howell continued under investigation for a diagnosis and was treated appropriately. Whilst the evidence at the Inquest did not indicate any contribution by delays in the scans to his death, I am concerned that upon the evidence given that the reporting of scans fell outwith an aimed for timescale of 5 days and that this could impact the treatment of others patients in the future . I am under a duty to report this matter upon consideration of the evidence.
” 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 Apply internal radiology reporting turnaround guidance that prioritizes examinations by modality, urgency and referral pathway.
Verbatim wording from the response “The prioritisation of image acquisition and reporting has to be tailored for different pathways, for example whilst it may be acceptable that outpatient reports are not provided on the day of acquisition, this is clearly not acceptable for emergency department patients. As there is no nationally mandated standard for the reporting turnaround of examinations at Mid Yorkshire NHS Hospitals, we apply our own guidance on the expected reporting turnaround times of radiology examinations. Different priority is given to different examinations depending on the modality (Xray, CT, MRI, Ultrasound), urgency of the request (as indicated by the referrer) and the referral source e.g. Emergency Department, Inpatient vs outpatient & GP referral. We are also asked to prioritise patients on fast track cancer pathways meaning” Source location 2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor radiology reporting turnaround times as a key performance indicator and report performance to divisional management and the Trust Board.
Verbatim wording from the response “Reporting turnaround times are a key performance indicator for the radiology department. As such they are monitored internally by the radiology department, divisional management team and reported to the Trust Board. As an organisation we strive to deliver the highest quality healthcare so this focus helps us to reduce the numbers of patients who wait longer than the internal target for an examination report. Given the complexity of the workload and the challenges meeting the reporting turnaround we have a risk management approach to the outstanding reporting. Unreported examinations wait within a prioritised queue with resource prioritised to the strategic objectives of the organisation focussing on acute/clinically urgent and cancer pathways. The routine outpatient work load waits longer to be reported.” Source location 2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Manage outstanding radiology reporting through a clinically prioritized queue, allocating resources to acute, urgent and cancer pathways to mitigate backlog risks.
Verbatim wording from the response “Reporting turnaround times are a key performance indicator for the radiology department. As such they are monitored internally by the radiology department, divisional management team and reported to the Trust Board. As an organisation we strive to deliver the highest quality healthcare so this focus helps us to reduce the numbers of patients who wait longer than the internal target for an examination report. Given the complexity of the workload and the challenges meeting the reporting turnaround we have a risk management approach to the outstanding reporting. Unreported examinations wait within a prioritised queue with resource prioritised to the strategic objectives of the organisation focussing on acute/clinically urgent and cancer pathways. The routine outpatient work load waits longer to be reported.” Source location 2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National standards and clear safety frameworks for radiology reporting turnaround times are assigned to national imaging, radiology and radiographer bodies.
Verbatim wording from the response “2. The National Imaging Optimisation Delivery Board should advise on national standards for report turnaround times, so that trusts can monitor and benchmark their performance.” Source location 2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The five-day reporting timeframe was incorrect for the routine outpatient CT examinations, and reporting delays did not contribute to the death.
Verbatim wording from the response “The matter of concern that you raise was “that upon the evidence given that the reporting of scans fell outwith an aim for timescale of 5 days and could impact the treatment of patients in the future”. Evidence at the inquest did not indicate that this had made any contribution to Mr Howell’s death.” Source location 2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current prioritisation, monitoring, internal turnaround guidance and risk-management arrangements are considered sufficient while reporting backlogs are managed.
Verbatim wording from the response “The prioritisation of image acquisition and reporting has to be tailored for different pathways, for example whilst it may be acceptable that outpatient reports are not provided on the day of acquisition, this is clearly not acceptable for emergency department patients. As there is no nationally mandated standard for the reporting turnaround of examinations at Mid Yorkshire NHS Hospitals, we apply our own guidance on the expected reporting turnaround times of radiology examinations. Different priority is given to different examinations depending on the modality (Xray, CT, MRI, Ultrasound), urgency of the request (as indicated by the referrer) and the referral source e.g. Emergency Department, Inpatient vs outpatient & GP referral. We are also asked to prioritise patients on fast track cancer pathways meaning” Source location 2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Open published response
25 Oct 2018 Eileen Cooke · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 6 Failure to involve and inform families in complex discharge decisions View source Failure to ensure an adequate supply of prescribed medication during hastily arranged discharges View source Precipitous hospital discharges View source Failure of senior clinician coordination for complex care decisions View source Inadequate discharge preparation for wound care, pain control and required clinical skills View source Failure to complete multidisciplinary best-interests decision-making and formulate a management plan View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eileen Cooke · 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
Eileen Cooke, an 80-year-old woman with dementia, frailty, contractures and a fractured left ankle, died in Pinderfields Hospital on 21 December 2017. Concerns included the lack of a best-interests multidisciplinary meeting, her discharge to a nursing home with unresolved medical and care needs, inadequate preparation for wound dressing and pain control, and the risk posed to other patients by precipitously arranged hospital discharges.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve and inform families in complex discharge decisions
Wider context from the report “3. The family were not involved in her discharge from hospital at all. It was arranged in haste. Inadequate preparatory work had been done to establish how her wound dressing could be carried out and the pain control needed whilst this was done. No consideration was given to the skills required to achieve this, or the wisdom of involving a tissue viability nurse.
4. Evidence taken from healthcare professionals at the Inquest indicated that the 7.11.17 discharge was an error of judgement. It effectively passed an unresolved problem to a nursing home.
5. A ‘best interests’ meeting was required to assess her needs and formulate a management plan. This should have involved the orthopaedic surgeon, the vascular surgeon, nurses, a physio-therapist, a care of the elderly physician, a palliative care specialist, the general practitioner and the family. In the event no such meeting was arranged. It appeared difficult for senior clinicians to get hold of each other. Even if the issues proved unsolvable the family would have at least understood the position and could brace themselves for a period of palliative care, rather than being left in the dark.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure an adequate supply of prescribed medication during hastily arranged discharges
Wider context from the report “7. The Inquest heard further evidence that hastily arranged discharges from Pinderfields Hospital are not uncommon and as a result patients can be sent home without an adequate supply of prescribed medication (for example, because the hospital pharmacy has closed by the time the discharge is organised ).
8. Having heard the evidence relating to the treatment received by this vulnerable elderly lady, I am concerned that the safety of others may be put at risk by precipitously arranged discharges.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Precipitous hospital discharges
Wider context from the report “7. The Inquest heard further evidence that hastily arranged discharges from Pinderfields Hospital are not uncommon and as a result patients can be sent home without an adequate supply of prescribed medication (for example, because the hospital pharmacy has closed by the time the discharge is organised).
8. Having heard the evidence relating to the treatment received by this vulnerable elderly lady, I am concerned that the safety of others may be put at risk by precipitously arranged discharges .
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinician coordination for complex care decisions
Wider context from the report “3. The family were not involved in her discharge from hospital at all. It was arranged in haste. Inadequate preparatory work had been done to establish how her wound dressing could be carried out and the pain control needed whilst this was done. No consideration was given to the skills required to achieve this, or the wisdom of involving a tissue viability nurse.
4. Evidence taken from healthcare professionals at the Inquest indicated that the 7.11.17 discharge was an error of judgement. It effectively passed an unresolved problem to a nursing home.
5. A ‘best interests’ meeting was required to assess her needs and formulate a management plan. This should have involved the orthopaedic surgeon, the vascular surgeon, nurses, a physio-therapist, a care of the elderly physician, a palliative care specialist, the general practitioner and the family. In the event no such meeting was arranged. It appeared difficult for senior clinicians to get hold of each other. Even if the issues proved unsolvable the family would have at least understood the position and could brace themselves for a period of palliative care, rather than being left in the dark.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate discharge preparation for wound care, pain control and required clinical skills
Wider context from the report “3. The family were not involved in her discharge from hospital at all. It was arranged in haste. Inadequate preparatory work had been done to establish how her wound dressing could be carried out and the pain control needed whilst this was done. No consideration was given to the skills required to achieve this, or the wisdom of involving a tissue viability nurse.
4. Evidence taken from healthcare professionals at the Inquest indicated that the 7.11.17 discharge was an error of judgement. It effectively passed an unresolved problem to a nursing home.
5. A ‘best interests’ meeting was required to assess her needs and formulate a management plan. This should have involved the orthopaedic surgeon, the vascular surgeon, nurses, a physio-therapist, a care of the elderly physician, a palliative care specialist, the general practitioner and the family. In the event no such meeting was arranged. It appeared difficult for senior clinicians to get hold of each other. Even if the issues proved unsolvable the family would have at least understood the position and could brace themselves for a period of palliative care, rather than being left in the dark.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete multidisciplinary best-interests decision-making and formulate a management plan
Wider context from the report “1. Consideration was given to an amputation of her left leg at her groin but it was recognised this would entail significant risks for a frail lady aged 80 with a range of co-morbidities. A ‘best interests’ multi-disciplinary meeting was mooted but never organised.
2. She was nevertheless deemed medically fit to be discharged from hospital on 7 November 2017 despite the progressive deterioration of the soft tissues around her left ankle fracture site and painful ulceration between her thighs. At this point in time the question of amputation or an alternative management plan were unresolved . The discharge letter was produced by a ‘Trust Grade Doctor-Career Grade Level’ unknown to the family.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Care of the Elderly consultations for frail patients outside elderly care areas, including guidance on complex care and discharge planning.
Verbatim wording from the response “Wherever possible frail elderly patients are admitted to one of the Acute Care of the Elderly (ACE) Units. This ensures that a holistic approach is taken and a comprehensive geriatric assessment completed. When frail patients are admitted to other areas the care of the elderly department does offer consultations to help guide clinical care and discharge planning.” Source location 2018-0311-Response-Mid-Yorkshire-Hospitals
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 dedicated discharge coordinators on each Care of the Elderly ward to facilitate safe, timely discharge.
Verbatim wording from the response “Each of our Care of the Elderly wards has access to therapy teams who attend daily board rounds which occur on a Monday to Friday. Treatment and prospective discharge plans are discussed. This allows issues to be raised and concern addressed: such as how someone is going to manage at home or whether further information or time is needed. At these daily board rounds and safety huddles, therapists, nurses, doctors and discharge coordinators are present. Each of our care of the elderly wards has a dedicated discharge coordinator, who helps to facilitate safe and timely discharges of frail older patients. Once a patient is deemed medically fit, the therapists work to establish the baseline and whether a patient’s current needs have changed.” Source location 2018-0311-Response-Mid-Yorkshire-Hospitals
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 Use daily multidisciplinary board rounds and safety huddles to review treatment, discharge plans, patient needs and emerging concerns.
Verbatim wording from the response “Each of our Care of the Elderly wards has access to therapy teams who attend daily board rounds which occur on a Monday to Friday. Treatment and prospective discharge plans are discussed. This allows issues to be raised and concern addressed: such as how someone is going to manage at home or whether further information or time is needed. At these daily board rounds and safety huddles, therapists, nurses, doctors and discharge coordinators are present. Each of our care of the elderly wards has a dedicated discharge coordinator, who helps to facilitate safe and timely discharges of frail older patients. Once a patient is deemed medically fit, the therapists work to establish the baseline and whether a patient’s current needs have changed.” Source location 2018-0311-Response-Mid-Yorkshire-Hospitals
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 Operate the REACT multidisciplinary and multiagency service to support early assessment and safe discharge of elderly patients.
Verbatim wording from the response “On the two ACE Units, there is a dedicated multidisciplinary/mult iagency team named the RApid Elderly Assessment Care Team (REACT) – the Trust was one of the Phase One Sites for the Future Hospitals Programme at the Royal College of Physicians which supported the expansion of the service.” Source location 2018-0311-Response-Mid-Yorkshire-Hospitals
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 Reassess mobility and provide occupational therapy and physiotherapy assessments to identify discharge support needs.
Verbatim wording from the response “There are a number of possibilities for the discharge for frail older patients with most being discharged back to their usual place of residence. All patients who have had a deterioration in their mobility are reassessed by therapists. Frail older patients, regardless of their location as an inpatient, have access to occupational therapy assessments and if necessary physiotherapy. These therapy assessments allow patients and their relatives to obtain valuable information about other support available to them in the community.” Source location 2018-0311-Response-Mid-Yorkshire-Hospitals
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 Coordinate frail older patients’ discharge plans with patients, families, representatives and relevant care providers, including capacity and safeguarding considerations.
Verbatim wording from the response “Discharge plans for frail older patients are discussed with patients themselves and often their family or next of kin. In those who lack capacity to make decisions for themselves, discharge plans are discussed with relatives especially those who have Power of Attorney over health and well-being. The Trust has a safeguarding adult team to support clinical teams in their decisions and discussion if required.” Source location 2018-0311-Response-Mid-Yorkshire-Hospitals
Open published response
5 Oct 2017 Jennifer Ann Midgley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure of the drug administration chart to distinguish oral and intravenous paracetamol administration View source Lack of patient-weight reference for intravenous paracetamol administration 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
Jennifer Ann Midgley · 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
Jennifer Ann Midgley had chronic obstructive pulmonary disease, malnutrition, non-alcoholic fatty liver disease and cirrhosis. After fracturing her left femur and undergoing surgery, she received intravenous paracetamol that was not adjusted for her weight, and this was described as contributing to organ failure and her death. The concerns included unclear drug administration charting distinguishing oral from intravenous paracetamol and the lack of a recorded patient weight for intravenous dosing.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the drug administration chart to distinguish oral and intravenous paracetamol administration
Wider context from the report “(1) I was informed that the drug administration chart does not clearly distinguish between the administration of oral and intravenous paracetamol , nor does it have any reference to a patient's weight in respect of intravenous administration.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of patient-weight reference for intravenous paracetamol administration
Wider context from the report “(1) I was informed that the drug administration chart does not clearly distinguish between the administration of oral and intravenous paracetamol, nor does it have any reference to a patient's weight in respect of intravenous administration .
” Open source report
3 May 2017 Margaret Elizabeth Conway · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Difficulties in transferring patients with serious mental and physical health problems View source Geographical and operational separation of Acute Medical Wards Mental Health Services 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
Margaret Elizabeth Conway · 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
Margaret Elizabeth Conway, aged 68, was admitted to Pinderfields Hospital with diarrhoea, acute kidney injury and pancolitis after being transferred from Fieldhead Hospital. She suffered a cardiac arrest and died at 0110 hours on 3 September 2016; the inquest recorded natural causes, including acute myocardial infarction and acute severe colitis. The substantive concerns related to the challenges of transferring and caring for patients with both serious mental and physical health problems across geographically and operationally separate services.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in transferring patients with serious mental and physical health problems
Wider context from the report “With the assistance of Professor Stephen Curran, Consultant in Old Age Psychiatry and Clinical Lead who is based at Fieldhead Hospital and who was involved in Mrs Conway’s care, I wish to address the issue of patients experience in mental health issues and who are in-patients at Fieldhead Hospital but who have or developed physical health problems acutely which require treatment.
(1) The Acute Medical Wards Mental Health Services are geographically and operationally separate.
(2) Transfers of patients who are experiencing both serious mental and physical health problems can sometimes be very challenging.
(3) PLT Services are now more actively involved in patients transferring to the Acute Wards.
(4) Closer working such as joint ward rounds and NDT working should be explored as well as the development of a clear pathway/flowchart to facilitate closer working and in the longer-term the development and use of a shared resource with a small number of jointly funded and managed beds. Such measures would improve the care of patients with both severe physical and mental illness and also reduce the need for multiple transfers between the two organisations.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Geographical and operational separation of Acute Medical Wards Mental Health Services
Wider context from the report “With the assistance of Professor Stephen Curran, Consultant in Old Age Psychiatry and Clinical Lead who is based at Fieldhead Hospital and who was involved in Mrs Conway’s care, I wish to address the issue of patients experience in mental health issues and who are in-patients at Fieldhead Hospital but who have or developed physical health problems acutely which require treatment.
(1) The Acute Medical Wards Mental Health Services are geographically and operationally separate.
(2) Transfers of patients who are experiencing both serious mental and physical health problems can sometimes be very challenging.
(3) PLT Services are now more actively involved in patients transferring to the Acute Wards.
(4) Closer working such as joint ward rounds and NDT working should be explored as well as the development of a clear pathway/flowchart to facilitate closer working and in the longer-term the development and use of a shared resource with a small number of jointly funded and managed beds. Such measures would improve the care of patients with both severe physical and mental illness and also reduce the need for multiple transfers between the two organisations.
” Open source report
Concerns raised 9 Failure of receiving teams to identify and fill gaps in referral information View source Absence of procedures for MDT meetings to proactively follow up inadequately completed referral forms View source Failure to ensure identification and electronic transmission of recent radiological evidence View source Failure to identify and transfer key clinical information to receiving teams View source Failure to ensure identification and transfer of key referral information View source Lack of procedures to proactively obtain information to complete gaps in clinical history View source Inadequate training of junior doctors completing referral forms View source Lack of understanding of key information required in referrals View source Ineffective training for junior doctors completing referral forms View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothy Cooper · 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
Dorothy Cooper underwent elective surgery on 29 September 2014, after which complications included splenic injury, liver ischaemia and infarction, and poor nutritional status. She later developed overwhelming sepsis and died in hospital on 6 January 2015. The principal concerns were incomplete information in a referral to the receiving team and inadequate procedures for identifying and following up gaps in the clinical history.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of receiving teams to identify and fill gaps in referral information
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this .
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled , then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of procedures for MDT meetings to proactively follow up inadequately completed referral forms
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms .
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure identification and electronic transmission of recent radiological evidence
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and transfer key clinical information to receiving teams
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team . The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history . It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team , and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure identification and transfer of key referral information
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team , and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures to proactively obtain information to complete gaps in clinical history
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of junior doctors completing referral forms
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of key information required in referrals
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective training for junior doctors completing referral forms
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Participate in the Regional Imaging Collaborative to improve interoperability and image transfer between acute provider organisations across Yorkshire.
Verbatim wording from the response “3. The author would also like to make readers aware that a Regional Imaging Collaborative has just begun work to improve system interoperability and image transfer between acute provider organisations across Yorkshire. Both Leeds Teaching Hospitals and Mid Yorkshire Hospitals NHS Trusts are actively participating in that collaborative. (Project completion not expected until early 2017)” Source location 2015-0412-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
Verbatim wording from the response “2. The electronic transfer of imaging and other clinical data to support specialist opinions is well embedded, and appears to have functioned adequately in this case. Further promotion of the systems and processes by which this can be achieved will be distributed through our local Mid Yorkshire MDT’s. (completion by end of January 2016)” Source location 2015-0412-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
Verbatim wording from the response “The process of inter-provider transfer of care for patients on cancer pathways in West Yorkshire is being revised, collaboratively at present. Both The Mid Yorkshire Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are centrally involved in that improvement work. The main action to improve handover of cases like Mrs Cooper’s will be to embed the revised processes detailed in the Standard Operating Procedure being drafted subsequent to that review. We expect this will be embedded by the end of February 2016.” Source location 2015-0412-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the revised inter-provider transfer processes and maintain senior support for junior staff completing multidisciplinary team referral forms.
Verbatim wording from the response “1. The junior doctors completing the MDT referral pro forma were well supported by a senior supervising colleague, in this case by Mr Basheer. Education and training can always be improved, and once the Inter-Provider Transfer Standard Operating Procedures have been revised and published, the Mid Yorkshire Hospitals NHS Trust will embed the processes therein, and will ensure that junior medical staff completing MDT pro forma’s remain well supported (completion by the end of February 2016)” Source location 2015-0412-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic transfer of imaging and clinical data was well embedded and appears to have functioned adequately in this case.
Verbatim wording from the response “1. Through my regular clinical practice, and close working relationship with several of the MDT’s at Mid Yorkshire Hospitals, I am aware that the referral processes between local and specialist MDT’s at Leeds, are well embedded and this routinely includes transfer of imaging and pathology data. I have confirmed that the pertinent Mid Yorkshire radiological evidence (including reports) was transferred prior to the initial Leeds HPB MDT evaluation of this patient.” Source location 2015-0412-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Junior doctors completing referral forms were well supported by senior supervision, disputing that inadequate training caused the referral concern.
Verbatim wording from the response “1. The junior doctors completing the MDT referral pro forma were well supported by a senior supervising colleague, in this case by Mr Basheer. Education and training can always be improved, and once the Inter-Provider Transfer Standard Operating Procedures have been revised and published, the Mid Yorkshire Hospitals NHS Trust will embed the processes therein, and will ensure that junior medical staff completing MDT pro forma’s remain well supported (completion by the end of February 2016)” Source location 2015-0412-Response
Open published response
10 Apr 2015 Maurice Camfield · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 1 Failure to provide one-to-one nursing care in accordance with the agreed care plan 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
Maurice Camfield · 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
Maurice Camfield suffered a traumatic brain injury in a road traffic collision in Bangkok, was repatriated to the United Kingdom, and later died in an ambulance after becoming unresponsive during transfer to hospital. The substantive concern was that the agreed care plan requiring one-to-one nursing care at all times was not followed.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide one-to-one nursing care in accordance with the agreed care plan
Wider context from the report “I heard evidence at this Inquest from ████████ a Consultant in Neurological Rehabilitation who expressed the view that it was important that in Mr Camfield's case that those involved in his care and treatment should do so strictly in accordance with the agreed plan which dictated that he should have one to one nursing care at all times . ████████ stressed the importance of doing what was in our care plan which did not happen in Mr Camfield's case .
” Open source report
7 Nov 2014 Colin John Ireland · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Lack of an agreed protocol for seeking approval for emergency release to hospital View source Inadequate training of on-duty Governors in responding to medical emergencies View source Failure of the on-call system to provide reliable telephone access to the responsible approval function View source Failure to prioritise preservation of life over security concerns in emergency medical decisions View source Failure to appropriately act on clinical judgement of a potentially life-threatening condition 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
Colin John Ireland · 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
Colin John Ireland, a diabetic prisoner at HMP Wakefield, fell and fractured his left hip during exercise in icy weather on 11 February 2012. After surgery and discharge to the prison healthcare centre, he collapsed and died on 21 February 2012; the inquest recorded pulmonary thromboembolism and deep venous thrombosis. Concerns included delay in transferring him to hospital, difficulties with the high-security prison approval system, and the absence of an agreed protocol and training for Governors responding to medical emergencies.
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 Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed protocol for seeking approval for emergency release to hospital
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances . I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable delay.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of on-duty Governors in responding to medical emergencies
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken , in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances. I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable delay.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the on-call system to provide reliable telephone access to the responsible approval function
Wider context from the report “2. That the same Governor Grade Officer had difficulty in contacting by telephone the on-call [████████] for the High Security Prison Group to seek permission for Mr Ireland to be sent to hospital. Apparently, [████████] was not responding to her calls . I request that the Director of the High Security Prison Group specifically address this issue in response to this report. Fortunately, the Governor had through his own dealings with [████████] who was then the Director of High Security Prisons, his contact details who was then able to give the relevant permission. I understand that this was an unofficial approach which I do not criticise but would point out that other Duty Governors may not have had access to [████████] number, which would have lengthened the delay . It occurs to me that the on-call system is flawed and should be reviewed.
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise preservation of life over security concerns in emergency medical decisions
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances. I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable delay .
” 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 Mid Yorkshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately act on clinical judgement of a potentially life-threatening condition
Wider context from the report “1. That a Governor Grade Officer who had sole responsibility for the running of the Prison challenged the clinical judgement and decisions of both an experienced nurse and an on-call GP who believed that Mr Ireland had fractured his hip and that this was a potentially life-threatening condition and that he should be sent to hospital as an emergency .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations