New Cross Hospital

Health and care · Healthcare site

Pin Request correction

First report 2 Feb 2016•Latest report 2 Apr 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
6

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

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.

  1. Black Country

    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

  2. Black Country

    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. Black Country

    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

  4. Black Country

    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

  5. Black Country

    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

  6. Black Country

    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
Back to top

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