Concerns raised 1 Failure of the Close Observation Risk Assessment to clearly distinguish fall-related scoring factors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Judith Hughes · 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
Judith Hughes had significant heart disease, was admitted to hospital following a seizure and later worsening heart failure, and died at home at 0030 hours on 07 October 2020. The inquest heard concerns that ambiguity in the Trust’s Close Observation Risk Assessment could lead to incorrect scoring, insufficient observation, and an increased risk of falls and death.
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× 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Close Observation Risk Assessment to clearly distinguish fall-related scoring factors
Wider context from the report “The Inquest heard evidence about the Trust's use of the 'Close Observation Risk Assessment' (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including 'inpatient falls during this admission' and 'previous falls'. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation , increased risk of falls and death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Enhanced Care Risk Assessment Form to distinguish previous community falls from inpatient falls during the current admission.
Verbatim wording from the response “Mrs Hughes died over five years ago on 7th October 2020. Policies and Forms are, of course, subjected to regular review. As was mentioned at the inquest the relevant Form had already been revised in 2022 (a copy of the Policy which contains this is enclosed) following a routine review of the Policy.” Source location Response from North West Anglia Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the relevant Policy and Form within the next few months and take the coroner’s comments into account.
Verbatim wording from the response “The relevant Policy and Form are due to be reviewed again in the next few months and we will ensure that your comments are taken into account in this process.” Source location Response from North West Anglia Foundation Trust
Open published response
Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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× 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians care .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver training and education on fluid management and maintaining fluid-balance charts.
Verbatim wording from the response “C. Fluid Management
The Trust acknowledges historical concerns regarding fluid management and the maintenance of fluid balance charts, but significant training and education have since been provided. In Christian’s case, gaining intravenous access was challenging due to hypoperfusion caused by cardiogenic shock, resulting in fluids being administered later than ideal, leaving minimal time to evaluate the response.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide echocardiography training to trainees.
Verbatim wording from the response “B. Echocardiography
This case was not caused by an inability to perform an echocardiogram. Had cardiogenic shock been suspected, a Consultant Intensivist or an on duty Medical Registrar, who was also a trained Cardiology Registrar, could have performed the procedure. As was explained at the inquest hearing in October 2023, it is possible to train more clinicians to perform echocardiograms. However, for a clinician to maintain their accreditation to perform echocardiograms, it is obligatory to perform a certain number of echocardiograms annually. While Cardiologists and Intensivists routinely meet this requirement, it remains challenging for other specialty clinicians, including ED. Nevertheless, our trainees now receive echocardiography training.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Educate Emergency Department and intensive care clinicians about potential complications of Cyclizine.
Verbatim wording from the response “time Cyclizine was prescribed it was not known that Christian had a cardiomyopathy and was in cardiogenic shock. The working diagnosis was sepsis. Clinicians in both ED and ICU have now been made aware of the potential complications of Cyclizine.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand sepsis education and training through dedicated sepsis nurses, protocol-adherence monitoring and bi-monthly sepsis meetings.
Verbatim wording from the response “G. Blood Gases/Elevated Lactate
The sepsis guidelines are clear and once sepsis is suspected a venous blood gas should have been obtained when the initial blood samples were obtained at 19:00h. The Trust has since expanded its sepsis education and training, employing dedicated sepsis nurses who deliver the education and training, and monitor adherence to protocols and hold bi-monthly sepsis meetings.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Symphony digital medical-record system in the Emergency Department to improve record-keeping.
Verbatim wording from the response “M. Record-keeping
The maintenance of good documentation is something which is highlighted to all clinicians during their training and postgraduate education. In addition, the Trust introduced the Symphony medical records system (digital) into the Emergency Department in December 2018 and this has resulted in improvements in record-keeping. The issue of the jugular venous pressure and capillary refill time is not a matter related to documentation; it is an issue which relates to an incomplete examination by the ED Registrar. Once again, it is difficult to comment upon this in the absence of any evidence from the clinician. However, these issues have been highlighted to staff in ED.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install a central Emergency Department monitoring area with printers to retain and print alarm data.
Verbatim wording from the response “N. Data from Emergency Department Alarms
The parameters at which alarms are sounded can be adjusted by staff on a temporary basis. Notwithstanding this, the monitors are still visible to staff in the Resuscitation area. As was explained at the inquest, the Emergency Department has subsequently installed a central monitoring area with printers. There is therefore no problem in retaining or printing off data if this is required. Unfortunately, in Christian’s case, the Trust was not informed of any concerns in this respect until some considerable time after Christian’s death. The monitors that we had at that time would need to have been interrogated prior to being used on the next patient. This is no longer an issue with the new equipment that we have but once again data will only be stored for a limited period of time.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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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 Differential diagnosis was fundamental medical training, and the Trust was unaware of this being a recurring problem.
Verbatim wording from the response “I. Differential Diagnosis
The diagnosis in Christian’s case was one of sepsis/septic shock with cardiogenic shock overlooked due to its rarity in young patients. Differential diagnoses are a fundamental part of medical training and we are not aware of this being a recurring theme.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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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 case was not caused by inability to perform echocardiography; appropriately trained clinicians could have performed the procedure if cardiogenic shock was suspected.
Verbatim wording from the response “B. Echocardiography
This case was not caused by an inability to perform an echocardiogram. Had cardiogenic shock been suspected, a Consultant Intensivist or an on duty Medical Registrar, who was also a trained Cardiology Registrar, could have performed the procedure. As was explained at the inquest hearing in October 2023, it is possible to train more clinicians to perform echocardiograms. However, for a clinician to maintain their accreditation to perform echocardiograms, it is obligatory to perform a certain number of echocardiograms annually. While Cardiologists and Intensivists routinely meet this requirement, it remains challenging for other specialty clinicians, including ED. Nevertheless, our trainees now receive echocardiography training.” Source location Response from North West Anglia NHS Foundation 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 Existing escalation mechanisms were available; the relevant failure was recognising cardiogenic shock rather than an absence of escalation arrangements.
Verbatim wording from the response “Had this been recognised, existing escalation mechanisms, including an urgent review by the ED Consultant, who was also an Intensive Care Medicine Consultant, could have been utilised. Following a referral by ED to the General Physicians, patients are normally seen in time order unless there is a specific concern regarding the patient’s condition. In those circumstances, the General Physicians would have been asked to see Christian immediately. The more likely scenario in Christian’s case is that the Consultant in charge of ED that day would have been asked to see the patient on an urgent basis. The” Source location Response from North West Anglia NHS Foundation Trust
Open published response
Concerns raised 1 Lack of a method for ensuring clinician review of routine CT scan reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard David ROE · 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
Richard David Roe underwent scans that showed evidence of pancreatic cancer, but the recommended review of the scan was not completed. A later scan showed metastatic pancreatic cancer, and he subsequently died. The principal concern was that there was no current system to ensure routine CT scan reports were reviewed and actioned by clinicians.
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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a method for ensuring clinician review of routine CT scan reports
Wider context from the report “(1) The evidence revealed that there is currently no method for ensuring that routine CT scan reports are reviewed by clinicians . This is despite a similar occurrence in May 2021. The inquest heard that the Trust are investigating a new IT System which will be able to flag when such issues occur. However this is a medium/long term project with no current completion date known and there is no system in place at present to prevent a repeat of such an incident .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce monthly reports identifying unviewed routine radiology scans using the current radiology system.
Verbatim wording from the response “However, as you note, the implementation of the improved records system is some way off and as an interim measure we’ve reviewed the abilities of the current radiology system and it can, and will, produce reports of unviewed scans (initially monthly) which can then be followed up with the requesting clinicians and/or their departments. The ability of the present system to provide information in detail is limited and at the moment it will identify a large number of unviewed images (most of which would be expected and not a concern) but in liaison with the external providers of the system we expect to be able to refine the information to better identify any scans that have been overlooked.” Source location Response by North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve the electronic records system to include requested reports and enable tracking of report viewing.
Verbatim wording from the response “The Trust is in the process of improving its electronic records system so that it is comprehensive and includes all reports requested by clinicians including radiology reports. This is a substantial financial investment by the Trust both in terms of the technology and the staff time needed to implement it. The details of the system haven’t yet been finalised but it will give the Trust more management and audit options and it is expected to include an easier ability to track the viewing of all types of reports including those for routine radiology scans.” Source location Response by North West Anglia NHS Foundation Trust
Open published response
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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 Clinicians who request routine scans and their departments remain primarily responsible for reviewing reports.
Verbatim wording from the response “Reviewing scan reports appropriately and timeously has always been, and will remain, the primary responsibility of the clinicians who requested them and/or their departments. However that failed for Mr Roe and we accept that there needs to be a system to ensure that routine scans aren’t overlooked which isn’t dependent on individual clinicians or their departments.” Source location Response by North West Anglia NHS Foundation Trust
Open published response
Concerns raised 4 Lack of training on UVC and IO access View source Failure to ensure that all midwives apply correct cord blood sampling technique View source Failure to consider neonatal issues arising from the recommendations View source Lack of training on blood transfusion during neonatal resuscitation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amelia Barbosa · 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
Amelia Barbosa suffered an acute hypoxic injury immediately before delivery that continued during resuscitation, and she died in hospital on 13 December 2020 at 7 days old. Concerns included unreliable cord blood sampling, delays in obtaining vascular access and administering treatment, inadequate consideration of blood transfusion before resuscitation stopped, and delayed effective cooling. The report also raised concerns that learning and training on these issues had not been fully implemented.
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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training on UVC and IO access
Wider context from the report “2. While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access . I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops. The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all midwives apply correct cord blood sampling technique
Wider context from the report “1. While I heard evidence that there has been training for Midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over 2 years after this delivery, the Midwife gave evidence that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area. The expert and the Trust’s own Head of Midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust Midwives and there is a risk that in future cases those treating the baby will be falsely reassured by normal cord pH results which may not be accurate .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider neonatal issues arising from the recommendations
Wider context from the report “2. While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access. I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops. The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered . I am concerned that they require further action .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training on blood transfusion during neonatal resuscitation
Wider context from the report “2. While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access. I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops . The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce annual procedural updates for all doctors involved in neonatal care.
Verbatim wording from the response “Paediatric Registrar can be signed off they must be able to insert UVCs under observation. However, as the independent expert stated during the inquest, there are occasions when it is simply not technically possible to insert a UVC. Hence the decision in this case to try to gain intraosseous access to give drugs and fluids. I can also confirm that there is regular training for undertaking these procedures on the ATLS (Advance Trauma Life Support) course which clinicians attend every four years. In addition, the Trust will be introducing annual updates for these procedures from September of this year for all doctors involved in looking after neonates.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt a low threshold for blood transfusion during resuscitation, preferring blood boluses over fluids in line with 2021 NLS guidance.
Verbatim wording from the response “Your report also referred to training in relation to the provision of blood transfusions. Whether a blood transfusion is given during a resuscitation is a matter of clinical judgement for the clinician in charge of resuscitation. However, it has been accepted by our Paediatricians that there should be a low threshold for giving a blood transfusion. In particular, it is preferable to give a bolus with blood rather than fluids. This adopts the NLS (Newborn Life Support) Guidelines from 2021 which recommends this.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance requiring cord blood sampling from the clamped cord area and escalation to paediatricians for capillary sampling if unsuccessful.
Verbatim wording from the response “The first area of concern relates to the taking of cord blood samples by midwifery staff. You heard evidence at the inquest that the midwife in this case did indeed attempt to take a sample of blood from that part of the umbilical cord which had been clamped. Unfortunately, she was unable to obtain any blood from there and therefore obtained a sample from the unclamped part of the cord. Following the inquest the midwifery department has produced and issued a poster in relation to this. I have enclosed a copy of the poster which makes it clear that cord blood samples must be taken from the clamped area and not from any other part of the cord or placenta. If the midwife is unable to obtain any blood from this part of the cord then they are to inform the Paediatricians in order that they can take a capillary sample.” Source location Response from North West Anglia NHS Foundation Trust
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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 UVC insertion cannot always be achieved because it is a technically difficult procedure.
Verbatim wording from the response “As for UVC insertion, this is a technically difficult skill and UVCs are only inserted by Paediatric Registrars and Consultant Paediatricians. Before a” Source location Response from North West Anglia NHS Foundation Trust
Open published response
Concerns raised 1 Lack of clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital 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.
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AI-generated summary
Ethel Ann Beaumont · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ethel Ann Beaumont died on 11 May 2020 after developing nitrofurantoin-induced liver injury and liver failure while being treated before planned surgery. The report found that a significantly raised ALT result should have been followed up promptly and raised concerns about unclear responsibility between hospital and primary care for monitoring antibiotics prescribed at the hospital’s request.
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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital
Wider context from the report “that there is a lack of clarity between hospital and primary care as to which of them should be responsible for monitoring where a GP is prescribing an antibiotic on the request of the hospital that a patient is attending regularly for review. I am concerned that these pathways should be clarified and that there remains a risk of future death at present.
” Open source report
Concerns raised 4 Lack of widespread, regular, mandatory ongoing crisis-drill training for anaesthetists View source Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients View source Failure to ensure utilisation of capnography by clinical staff who may intubate patients View source Failure to observe capnography for up to 15 to 20 seconds after intubation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Saint · 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
Peter Saint was admitted for routine elective knee replacement surgery and died after an endotracheal tube was placed in his oesophagus, resulting in approximately 38 minutes without effective lung ventilation and subsequent hypoxic brain damage. The principal concerns were inadequate understanding and interpretation of capnography, failure to follow the required confirmation procedure after intubation, and insufficient ongoing training for anaesthetists in crisis situations.
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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of widespread, regular, mandatory ongoing crisis-drill training for anaesthetists
Wider context from the report “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias” , and that such training would be beneficial.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients
Wider context from the report “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients.
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure utilisation of capnography by clinical staff who may intubate patients
Wider context from the report “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to observe capnography for up to 15 to 20 seconds after intubation
Wider context from the report “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error” . I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him . The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement multidisciplinary human-factors training, including preparation of staff to train colleagues and rolling delivery to theatre staff.
Verbatim wording from the response “A consultant obstetrician with expertise in Human Factors has been commissioned to provide training to anaesthetists and theatre staff. Multidisciplinary teams, consisting of consultant anaesthetists, operating department practitioners and theatre nurses, are being recruited. These teams will be trained to train, following which they will deliver training to other staff on a rolling basis throughout the year. A steering group, composed of the Associate Divisional Director (consultant anaesthetist), matrons and theatre” Source location 2017-0404-Response-by-North-West-Anglia-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver high-fidelity airway simulation training covering capnography, technical airway skills, human factors and crisis-management skills to all Hinchingbrooke anaesthetic staff.
Verbatim wording from the response “All members of the anaesthetic department at Hinchingbrooke are to participate in an airway simulation course at a high fidelity simulation centre. We have identified a suitable course and are in the process of planning training with the course provider. It is a one day course for anaesthetist-DOP teams that combines human factors with airway technical skills. It includes interactive team training, simulation, error avoidance strategy, airway-technical skills, human factors in crisis management and practical briefing/debriefing skills. Due to the logistics of having all of the anaesthetists attending external training, while continuing to staff the service for patients it will be necessary to run the course on multiple dates. This course will address the specific issues regarding the use and interpretation of capnography that were raised in your letter.” Source location 2017-0404-Response-by-North-West-Anglia-NHS-Trust
Open published response
5 Dec 2014 Elaine Marilyn GILES · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 2 Failure to ensure adequate support is available in the home environment View source Lack of detailed assessment of likely functional performance in home circumstances after discharge 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.
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AI-generated summary
Elaine Marilyn GILES · 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
Elaine Marilyn GILES, a 66-year-old woman, died from fat embolism after falling while descending the stairs at home five days after discharge following hip replacement surgery. The principal concern was that she had been assessed as safe on stairs before discharge but could not safely negotiate the stairs at home, highlighting the need for detailed assessment of likely function in the home and adequate support after discharge.
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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate support is available in the home environment
Wider context from the report “Whilst assessed as "safe" on stairs prior to discharge from Peterborough City Hospital, it is very clear that Elaine could not negotiate stairs safely when she got home. This tragic case draws attention to the need for detailed assessments of a patient's likely functional performance in their home circumstances after discharge and the importance of ensuring adequate support is available in the home environment .
” 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 North West Anglia NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed assessment of likely functional performance in home circumstances after discharge
Wider context from the report “Whilst assessed as "safe" on stairs prior to discharge from Peterborough City Hospital, it is very clear that Elaine could not negotiate stairs safely when she got home. This tragic case draws attention to the need for detailed assessments of a patient's likely functional performance in their home circumstances after discharge and the importance of ensuring adequate support is available in the home environment.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations