Recipient

New Cross Hospital

First report 2 Feb 2016•Latest report 2 Apr 2019

Recipient record

Reports, concerns and published responses

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

Reports: 6
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from New Cross Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

2 Apr2019
Black Country
Concerns raised3
1. Inadequate communication between the hospital and occupational therapist
2. Insufficient urgency in resolving the matter
3. Minimal exercise and mobility regime
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

Mrs Elsa Reid · 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

Mrs Elsa Reid, a 92-year-old woman, was admitted to hospital after a fall that caused a complex fractured hip and was later discharged to a care home for rehabilitation. She died on 20 December 2018 after developing a pulmonary embolism. The principal concerns were inadequate communication about her mobility and hoisting needs, delays in resolving conflicting instructions, and an insufficient mobility regime that may have increased the risk of complications including pulmonary embolism.

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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication between the hospital and occupational therapist
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication between the Hospital and occupational therapist to resolve the issue in a timely manner which resulted in a minimal exercise/mobility regime being implemented. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient urgency in resolving the matter
Wider context from the report
“2. Although it is recognised some bed bound exercises were completed there was insufficient urgency amongst those professionals involved to resolve the matter as quickly as possible and thereby reduce the risks of complications, including pulmonary embolism from developing. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Minimal exercise and mobility regime
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication between the Hospital and occupational therapist to resolve the issue in a timely manner which resulted in a minimal exercise/mobility regime being implemented. ”
Open source report
4 May2017
Black Country
Concerns raised4
1. Insufficient ward capacity for patients requiring continuous observation
2. Lack of capacity to safely manage additional confused, wandering or aggressive patients
3. Failure to ensure admission decisions reflect senior clinical assessment of patient suitability
1. Failure to maintain supervision of patients when family visitors leave the ward
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

Mr Reginald Frank Lewis · 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 Reginald Frank Lewis was admitted to hospital after a fall, later fell again while on Ward C19 and sustained a head injury causing an intracerebral bleed; he died on 17 January 2017. Concerns included inadequate communication of his confusion, falls risk and blindness during transfer, his being left unsupervised after family visitors left, and pressure to accept him into a ward already managing several patients requiring continuous observation.

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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient ward capacity for patients requiring continuous observation
Wider context from the report
“2. On ward c19, there were already six patients on the ward required to be observed 24 hours a day in two bays. Two bays were subsequently closed to diarrhoea and vomiting. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of capacity to safely manage additional confused, wandering or aggressive patients
Wider context from the report
“3. Evidence emerged from nursing staff on Ward C19 that they were unable to take any more patients that are confused, wandering or aggressive. This was based on the enhanced scoring tool and the number of patients that required one to one observation. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure admission decisions reflect senior clinical assessment of patient suitability
Wider context from the report
“4. Despite initial reservations, junior nursing staff did eventually accept Mr Lewis into Ward C19 on the basis he had mild confusion and claimed they felt “under some pressure” from senior nursing staff to accept him. This was in contrast to the opinion of the senior Charge Nurse on ward C19 who gave evidence that he still would not have accepted the patient in the circumstances. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain supervision of patients when family visitors leave the ward
Wider context from the report
“1. Evidence emerged during the inquest that the patient was left alone unsupervised when family visitors left the ward. It transpired that staff didn’t know relatives had left the ward. ”
Open source report
3 Apr2017
Black Country
Concerns raised1
1. Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge
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

Ms Abigail Baynham · 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 Abigail Baynham had a history of suicidal ideation and was found deceased at her flat after taking her own life. The inquest heard that no further referral to the Mental Health Liaison Service was made when she left hospital, which may have led to a further assessment of her mental state and risk of self-harm.

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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge
Wider context from the report
“1. Evidence emerged during the inquest that when Ms Baynham had left hospital on the 22 November 2017, there was no further referral made back to Mental Health Liaison Service. This may have triggered a further assessment about her mental state and risk of self-harm. ”
Open source report
17 Oct2016
Black Country
Concerns raised3
1. Over-reliance on fall or trauma significance in initial triage assessment
2. Failure to maintain observation before determining triage priority
3. Delays in observations and blood tests when potential infection is present
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

Mr Vinod Kumar · 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 Vinod Kumar became seriously ill after developing flu-like symptoms and sustaining a graze to his right arm in a fall. He was diagnosed with sepsis secondary to necrotising fasciitis and died shortly after surgery on 10 August 2016. The concerns related to the initial emphasis on the fall, the lack of further observations or blood tests for about three hours, and whether he should have remained under observation before triage categorisation.

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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Over-reliance on fall or trauma significance in initial triage assessment
Wider context from the report
“1. Evidence emerged during the inquest that when he was seen initially by the Triage nurse, that too much emphasis and reliance was placed on the significance of the fall/trauma. Evidence of potential infection (swelling to his arms) resulted in no further observations or blood tests done until some three hours later. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain observation before determining triage priority
Wider context from the report
“2. Evidence from the A and E Consultant emerged from the inquest which suggested that it would have been good practice to keep the patient under further observation before determining his level of priority in terms of categorisation. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in observations and blood tests when potential infection is present
Wider context from the report
“1. Evidence emerged during the inquest that when he was seen initially by the Triage nurse, that too much emphasis and reliance was placed on the significance of the fall/trauma. Evidence of potential infection (swelling to his arms) resulted in no further observations or blood tests done until some three hours later. ”
Open source report
24 Feb2016
Black Country
Concerns raised3
1. Failure to provide further hospital observation after a potential red-flag ECG finding
2. Failure to recognise and accurately record an abnormal ECG indicating a potential pulmonary embolism
3. Failure to undertake further diagnostic testing for a possible pulmonary embolism
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

Mrs Marie Rollason · 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

Mrs Marie Rollason sustained a head injury in a fall and was discharged after a CT scan showed no fractures or haemorrhages. She subsequently experienced repeated loss of consciousness and was discharged again after an ECG abnormality was recorded as “okay”. The report identifies concerns that this was a missed opportunity for further observation and basic medical care; she later collapsed and died, with the inquest recording pulmonary embolism as the cause of death, contributed to by neglect.

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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide further hospital observation after a potential red-flag ECG finding
Wider context from the report
“2. When she was admitted back to the Hospital on the 23 December 2015, an ECG trace revealed an abnormality in the trace which can be indicative of changes that occur during a pulmonary embolism. However the Junior Doctor recorded the ECG trace "was okay". She wasn't kept in for further observation but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP. This was effectively a missed opportunity to render basic medical care. 3. The Consultant who gave evidence suggested that the ECG trace was a potential “Red flag” and he would have admitted her for further observation given that she had no previous cardiac related complaints and to try and understand the basis for her loss of consciousness. He went on to confirm in his opinion that on the balance of probability this was a failure in basic medical care. 4. Moreover, during the inquest the Consultant gave evidence that in his opinion, had she been kept in Hospital and observed, then on the balance of probability it is more likely than not she may have survived. Further tests including the D-Dimer test could have been done to confirm the diagnosis and appropriate treatment commenced. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise and accurately record an abnormal ECG indicating a potential pulmonary embolism
Wider context from the report
“2. When she was admitted back to the Hospital on the 23 December 2015, an ECG trace revealed an abnormality in the trace which can be indicative of changes that occur during a pulmonary embolism. However the Junior Doctor recorded the ECG trace "was okay". She wasn't kept in for further observation but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP. This was effectively a missed opportunity to render basic medical care. 3. The Consultant who gave evidence suggested that the ECG trace was a potential “Red flag” and he would have admitted her for further observation given that she had no previous cardiac related complaints and to try and understand the basis for her loss of consciousness. He went on to confirm in his opinion that on the balance of probability this was a failure in basic medical care. 4. Moreover, during the inquest the Consultant gave evidence that in his opinion, had she been kept in Hospital and observed, then on the balance of probability it is more likely than not she may have survived. Further tests including the D-Dimer test could have been done to confirm the diagnosis and appropriate treatment commenced. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake further diagnostic testing for a possible pulmonary embolism
Wider context from the report
“2. When she was admitted back to the Hospital on the 23 December 2015, an ECG trace revealed an abnormality in the trace which can be indicative of changes that occur during a pulmonary embolism. However the Junior Doctor recorded the ECG trace "was okay". She wasn't kept in for further observation but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP. This was effectively a missed opportunity to render basic medical care. 3. The Consultant who gave evidence suggested that the ECG trace was a potential “Red flag” and he would have admitted her for further observation given that she had no previous cardiac related complaints and to try and understand the basis for her loss of consciousness. He went on to confirm in his opinion that on the balance of probability this was a failure in basic medical care. 4. Moreover, during the inquest the Consultant gave evidence that in his opinion, had she been kept in Hospital and observed, then on the balance of probability it is more likely than not she may have survived. Further tests including the D-Dimer test could have been done to confirm the diagnosis and appropriate treatment commenced. ”
Open source report
2 Feb2016
Black Country
Concerns raised3
1. Lack of continuity and overall ownership of treatment in general practice
2. Failure to identify red flags and obtain second opinions or further tests for prolonged unexplained symptoms
3. Failure to review GP medical records during hospital admissions for young children
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

Baby Ryan Singh Bhogal · 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

Ryan was a healthy baby and toddler who experienced increasingly frequent medical visits and multiple symptoms before being diagnosed with acute myeloid leukaemia and dying on 11 September 2015. The principal concerns were a lack of continuity and overall ownership in GP care, possible missed red flags and opportunities for earlier testing, and hospital systems for reviewing GP medical records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of continuity and overall ownership of treatment in general practice
Wider context from the report
“1. There was a lack of continuity and overall ownership in terms of treatment Ryan received at the GP practice. He was seen by different Doctor’s including Locum staff with no overall holistic approach. This surgery may wish to consider reviewing their policy and management of children who appear excessively for treatment to ensure that there is continuity of care and appropriate measures are in place. In addition you may wish to consider reviewing the systems in place in identifying “Red Flags” and seeking a second opinion or requesting further tests where symptoms or unexplained illnesses are identified for an extended period. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify red flags and obtain second opinions or further tests for prolonged unexplained symptoms
Wider context from the report
“1. There was a lack of continuity and overall ownership in terms of treatment Ryan received at the GP practice. He was seen by different Doctor’s including Locum staff with no overall holistic approach. This surgery may wish to consider reviewing their policy and management of children who appear excessively for treatment to ensure that there is continuity of care and appropriate measures are in place. In addition you may wish to consider reviewing the systems in place in identifying “Red Flags” and seeking a second opinion or requesting further tests where symptoms or unexplained illnesses are identified for an extended period. ”
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 New Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to review GP medical records during hospital admissions for young children
Wider context from the report
“2. The Royal Wolverhampton NHS Trust may wish to consider reviewing their policy in relation to when it is appropriate to review GP medical records during Hospital admissions. This is particularly important for young children in order to have a clearer history of the patient’s presentation before reaching a diagnosis and treatment regime. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Inadequate communication between the hospital and occupational therapist

Insufficient urgency in resolving the matter

Minimal exercise and mobility regime

Concerns raised4

Insufficient ward capacity for patients requiring continuous observation

Lack of capacity to safely manage additional confused, wandering or aggressive patients

Failure to ensure admission decisions reflect senior clinical assessment of patient suitability

Failure to maintain supervision of patients when family visitors leave the ward

Concerns raised1

Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge

Concerns raised3

Over-reliance on fall or trauma significance in initial triage assessment

Failure to maintain observation before determining triage priority

Delays in observations and blood tests when potential infection is present

Concerns raised3

Failure to provide further hospital observation after a potential red-flag ECG finding

Failure to recognise and accurately record an abnormal ECG indicating a potential pulmonary embolism

Failure to undertake further diagnostic testing for a possible pulmonary embolism

Concerns raised3

Lack of continuity and overall ownership of treatment in general practice

Failure to identify red flags and obtain second opinions or further tests for prolonged unexplained symptoms

Failure to review GP medical records during hospital admissions for young children