Concerns raised 4 Lack of understanding among non-stroke specialist clinicians about when and where thrombectomy services are available View source Lack of regional mutual aid for thrombectomy View source Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire View source Failure to deliver a 24/7 thrombectomy service in Lancashire 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
Michelle Julie Marie Michaela MASON · 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
Michelle Julie Marie Michaela MASON died on 1 June 2024 at Royal Infirmary, Lancaster, after sudden onset of lack of vision, vomiting and severe pain. She was reviewed around six hours later, when thrombolysis was no longer possible; thrombectomy was considered but no local service was available and transfer was considered too late. Concerns included the absence of a 24/7 thrombectomy service in Lancashire, limited understanding among non-stroke specialists about thrombectomy availability, and a lack of regional mutual aid.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding among non-stroke specialist clinicians about when and where thrombectomy services are available
Wider context from the report “(2) There is a lack of understanding from non-stroke specialist clinicians in Lancashire as to when and where thrombectomy services are available for patients in Lancashire
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regional mutual aid for thrombectomy
Wider context from the report “(3) There is no mutual aid regionally , even where thrombectomy is available, clinically appropriate, it is known lack the procedure is likely to result in death and it is anticipated resources are available to complete the procedure.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire
Wider context from the report “(1) NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver a 24/7 thrombectomy service in Lancashire
Wider context from the report “(1) NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service
” 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 Work with regional stakeholders and clinicians to explore and progress plans for overnight thrombectomy access across Lancashire and South Cumbria.
Verbatim wording from the response “These challenges are recognised by NHS England (“NHSE”) and are the subject of ongoing discussions. It is our understanding that the service provided from Royal Preston Hospital now covers 7 days per week, 8am – 10pm. The team here at Northern Care Alliance will continue to work with NHSE, Lancashire Teaching Hospitals and the Walton Centre to explore options to provide the Lancashire and South Cumbria catchment with access to this service overnight. A meeting between the Trust, NHSE and Lancashire Teaching Hospitals took place on 15 July 2025 to discuss this, where possible options for providing aid overnight were explored. Follow-up meetings will include representation from all NW thrombectomy providers to ensure all possibilities are thoroughly explored and aim to progress plans and clarify timelines. We will work with our clinicians to support this process.” Source location Response from Northern Care Alliance 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 Concerns about thrombectomy provision and clinician understanding in Lancashire fall outside the Trust’s commissioned Greater Manchester functions.
Verbatim wording from the response “The Northern Care Alliance NHS Foundation Trust (“the Trust”) is commissioned to provide mechanical thrombectomy services across Greater Manchester. The Trust is not in a position to respond to the first and second areas of concern.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
4 Mar 2025 Mark Anthony Fernandez · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to utilise hospital passports View source Failure to provide adequate information about care needs in referrals to specialist services View source Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Implement Patient Care Alert procedures to verify contact details, contact care providers, obtain Hospital Passports, and record unresolved information for nursing follow-up.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Complete the multidisciplinary review of the Enhanced Patient Observation policy to address learning disability needs and active Hospital Passport use.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Add a Hospital Passport prompt and learning disability indicator to the patient-status-at-a-glance board.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Use and further develop the Enhanced Patient Observation audit tool and targeted training to improve person-centred observation practice and quality assurance.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Disseminate the Share Learning Take 5 education on learning disability care, diagnostic overshadowing, communication, Hospital Passports and carer involvement.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Red-flag patients with learning disabilities or Hospital Passports in daily safety huddles and assign senior nurse oversight of vulnerable patients.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Continue quarterly Senior Nurse Walkabout reviews of learning disability identification, safety-huddle flags, Hospital Passport availability and currency.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source See 8 more actions
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AI-generated summary
Mark Anthony Fernandez · 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
Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to utilise hospital passports
Wider context from the report “1. The hospital passport was not utilised .
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate information about care needs in referrals to specialist services
Wider context from the report “1. The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take account of long-term carers' and social services' views and knowledge in best interest decisions
Wider context from the report “1. The hospital passport was not utilised.
2. A best interest decision was made without taking into account the views of the long-term carers and social services and their knowledge of him as an individual .
” 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 Patient Care Alert procedures to verify contact details, contact care providers, obtain Hospital Passports, and record unresolved information for nursing follow-up.
Verbatim wording from the response “Patient Care Alert (“PCA”)” Source location Response from Northern Care Alliance 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 Roll out and develop the updated mental-capacity ward audit programme, including training lead nurses and reporting findings through governance groups.
Verbatim wording from the response “MCA audits” Source location Response from Northern Care Alliance 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 Deliver commissioned education sessions on Mental Capacity Act incapacitated-consent requirements and the importance of carers’ views in best-interest decisions.
Verbatim wording from the response “MCA training” Source location Response from Northern Care Alliance 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 Complete the multidisciplinary review of the Enhanced Patient Observation policy to address learning disability needs and active Hospital Passport use.
Verbatim wording from the response “Review of the Learning and Disabilities and Autism policy and Enhanced Patient Observation (“EPO”) policy” Source location Response from Northern Care Alliance 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 Add a Hospital Passport prompt and learning disability indicator to the patient-status-at-a-glance board.
Verbatim wording from the response “3. A prompt will now appear on the ‘patient status at a glance’ board (the bed board) when a Hospital Passport is available and in use. This will reiterate the policy provision with regard to the visibility and prominence of Hospital Passports. The board features a learning disability symbol and staff can include written confirmation of “Hospital Passport in place”.” Source location Response from Northern Care Alliance 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 and further develop the Enhanced Patient Observation audit tool and targeted training to improve person-centred observation practice and quality assurance.
Verbatim wording from the response “The Enhanced Patient Observation (“EPO”) policy review and audit tool” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.
Verbatim wording from the response “Review of the Learning and Disabilities and Autism policy and Enhanced Patient Observation (“EPO”) policy” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the Share Learning Take 5 education on learning disability care, diagnostic overshadowing, communication, Hospital Passports and carer involvement.
Verbatim wording from the response “Share Learning Take 5” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Define Mental Capacity Act and Deprivation of Liberty Safeguards training to support wider practical application beyond DoLS authorisation.
Verbatim wording from the response “The Trust Level 3 safeguarding adult mandatory training programme has a significant focus on the MCA and its application in practice. Current organisational compliance with Level 3 Safeguarding adult training is at 95%. MCA and Deprivation of Liberty Safeguards (DoLS) training have been better defined to support the application of MCA beyond the requirement for application of a DoLS authorisation to ensure the MCA is more effectively considered for a wider group of patients, including those with learning disabilities. The application of the MCA is essential to the EPO procedures to ensure the least restrictive option of observation and support is provided.” Source location Response from Northern Care Alliance 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 Red-flag patients with learning disabilities or Hospital Passports in daily safety huddles and assign senior nurse oversight of vulnerable patients.
Verbatim wording from the response “Daily safety huddles
Further to the PCA, any patient with a learning disability/Hospital Passport will automatically be ‘red flagged’ during daily safety huddles for nursing staff. This adds a further layer of awareness of this cohort of patients and their specific needs. The senior nurse (ward manager) will have oversight of vulnerable patients.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue quarterly Senior Nurse Walkabout reviews of learning disability identification, safety-huddle flags, Hospital Passport availability and currency.
Verbatim wording from the response “Senior Nurse Walkabout” Source location Response from Northern Care Alliance 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 initial absence of the Hospital Passport did not impact the patient’s care, although its immediate availability remains important.
Verbatim wording from the response “The Trust’s review determined that Mr Fernandez’s care was not impacted by the initial absence of the Hospital Passport. Notwithstanding this however, the Trust recognises that it’s proper utilisation depends on hospital staff being immediately aware as to the need for this document to accompany a patient with a learning disability or if one is not available to create one.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
8 Nov 2024 Anne Taylor · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Failure to assess capacity to decide to leave hospital View source Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment View source Failure to consider secondary investigations during clinical waiting times View source Delays in clinical assessment resulting in patients leaving hospital before assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anne Taylor · 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
Anne Taylor sustained a head injury after banging her head on a bedside cabinet and falling from a bed during a holiday. After initially leaving hospital before assessment because of waiting times, she returned the next day and was diagnosed with a traumatic brain injury involving bilateral acute subdural bleeding and midline shift; she deteriorated and died on 31 July 2024. Concerns included the lack of consideration of investigations during the waiting period, the absence of evidence that her capacity to leave was assessed, and uncertainty about a new procedure for patients leaving before clinical assessment.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess capacity to decide to leave hospital
Wider context from the report “3. No evidence was provided that the deceased’s capacity to decide to leave the hospital was assessed given the history of suspected head injury .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment
Wider context from the report “4. Reference was made to a new standard operating procedure being developed relating to patients leaving the hospital before a clinical assessment occurs, but it was unclear what this will include .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider secondary investigations during clinical waiting times
Wider context from the report “2. There was no consideration of whether secondary investigations could be undertaken during the waiting time for example CT scan which would likely be required by a clinician in order to make a diagnosis.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in clinical assessment resulting in patients leaving hospital before assessment
Wider context from the report “1. During evidence, it was heard that the deceased had elected to leave the Hospital on Friday 19 July because of waiting times, before being clinically assessed .
” 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 Disseminate the approved Standard Operating Procedure across urgent and emergency care areas.
Verbatim wording from the response “A Standard Operating Procedure (SOP) for patients who leave the emergency department whilst waiting to be seen has now been drafted and is going through NCA approval processes, with an estimated approval date of 6th February 2025. We append the working draft for your information. This guideline sets out the responsibilities of clinical and nursing staff when an adult leaves an emergency care setting prior to being assessed or receiving treatment, so that the patient is safeguarded appropriately with the aim of:” Source location Response from Northern Care Alliance
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 Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.
Verbatim wording from the response “In addition to the above, as of 25th November 2024, Salford Royal Hospital has become an early adopter of the NHSE Acuity Tool, an initial assessment model which aims to standardize the measurement of acuity in Emergency Departments and Urgent Treatment Centres. Patients who attend the ED at Salford Royal now receive an initial, primary assessment to identify patients with an acuity 1, 2 or 5 which will allow them to either be directed immediately to a receiving location or be directed to an alternative provider such as primary care. Acuity 1 patients are those with immediate life/limb threatening illness/injury, acuity 2 are those with imminent life/limb threatening illness/injury and acuity 5 denotes no threat to life or limb, no ED specific resource necessary. Patients who do not meet an acuity 1, 2 or 5 will then go on to receive a secondary assessment.” Source location Response from Northern Care Alliance
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 Develop and obtain approval for a Standard Operating Procedure governing patients leaving the emergency department before assessment or treatment.
Verbatim wording from the response “Additionally, it was highlighted that at the time of Mrs Taylor’s attendance there was no formalized Standard Operating Procedure within Salford Royal’s Emergency Department defining the actions to take when a patient leaves before clinical assessment. Salford site has an electronic self-discharge checklist designed for ward-based use, but no guidance or policy to describe the appropriate completion of this, or relevant steps to take, in the emergency department setting.” Source location Response from Northern Care Alliance
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 Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.
Verbatim wording from the response “The target time for secondary assessment is 15 minutes, Salford Care Organisation are on track to achieve this. Progress of the early adopter programme is being shared with NHSE at regular intervals. Patients receiving a secondary assessment can be identified for early clinical intervention and front loading of essential investigations such as, CT scan. Work is ongoing to meet the NHSE secondary assessment target to provide the significant benefits it offers of reducing the risk of patients with serious conditions sitting in the waiting room for a long time undiagnosed. In addition, the new acuity tool, has a specific question regarding mental capacity assessment relating to a patient’s decision to leave the department.” Source location Response from Northern Care Alliance
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 Consider and frontload secondary investigations, including CT scanning, for head-injury patients meeting NICE criteria while they await clinical review.
Verbatim wording from the response “The review determined that going forwards secondary investigations (such as a CT scan) should be considered and frontloaded for patients who are identified as meeting NICE guidelines criteria for CT scan in head injury, whilst they await clinical review. The new NHSE Acuity tool process described below will support this.” Source location Response from Northern Care Alliance
Open published response
8 Aug 2024 Mary Margaret Horgan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of shared understanding and expectations between medical teams about how Patient Pass operates View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Margaret Horgan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Margaret Horgan fell at home and sustained a traumatic cervical spinal injury with fracture dislocation and severe spinal cord compression. After delays and communication difficulties surrounding MRI interpretation and the Patient Pass referral system, she was transferred to hospital and placed on end-of-life care, dying on 5 June 2023. The principal concern was uncertainty and confusion between medical teams about how Patient Pass operated, which could put patients’ lives at risk.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding and expectations between medical teams about how Patient Pass operates
Wider context from the report “Whist the inquest found, on the evidence, that the transfer of Mrs Horgan between hospitals without an Aspen collar and spinal precautions as advised did not significantly contribute to her death, the obvious disparity revealed by the evidence between the two medical teams of their respective understanding and expectations of the way in which Patient Pass operates serves to create uncertainty and confusion and could easily give rise to a situation where the lives of patients may be put at risk .
” 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 Finalise and circulate a communications guide clarifying Patient Pass purposes and referrer and receiver responsibilities across Greater Manchester hospitals.
Verbatim wording from the response “As a result, we have prepared a communications guide, which outlines the purpose of Patient Pass and clarifies the responsibilities of referrers and receivers. This document is due to be finalised shortly and will be circulated across Greater Manchester hospitals via their Medical Directors.” Source location Response from Northern Care Alliance
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 Add a new-user Patient Pass screen explaining user responsibilities and requiring acceptance before system access.
Verbatim wording from the response “In order to assist with improving the operation of Patient Pass, the Trust is collaborating with the Patient Pass developers to make changes to the system as follows:” Source location Response from Northern Care Alliance
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 Convene a cross-Trust working group, review the incident, and agree actions to improve understanding and operation of Patient Pass.
Verbatim wording from the response “The Trust has convened a working group, including ████████, Consultant Vascular Radiologist and lead for Quality and Patient Safety from MFT to discuss how we can improve and strengthen communication between the Trusts, and to gain input and perspective from MFT as an external referrer. This group has reviewed this incident, and agreed a number of actions to both improve understanding of the Patient Pass system and improve the system itself to reduce the likelihood of recurrence of such an incident.” Source location Response from Northern Care Alliance
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 Create, consult on, and circulate a seven-minute Greater Manchester briefing sharing learning on applying transfer policies and using Patient Pass.
Verbatim wording from the response “In line with a request from the Greater Manchester Integrated Care Board, the Trusts are creating a seven-minute briefing document to share learning across Greater Manchester regarding the need to fully apply our transfer policies and to highlight the learning around the use of the Patient Pass system. We will consult with Dr Dare Seriki to prepare and circulate this in October 2024.” Source location Response from Northern Care Alliance
Open published response
30 Nov 2023 Donna Marie Donnellan · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service View source Lack of clarity about the role and remit of the Mental Health Liaison Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Donna Marie Donnellan · 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
Donna Marie Donnellan had a long-standing history of disordered eating, severe weight loss and peripheral neuropathy. She was found deceased at home on 10 October 2022, and the investigation recorded death from complications arising from malnutrition likely due to an undiagnosed atypical eating disorder. Concerns included unclear roles between acute clinicians and the Mental Health Liaison Team, and a lack of understanding about referral pathways to specialist eating disorder services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of referral and advice-seeking pathways to the Specialist Eating Disorder Service
Wider context from the report “2) There was a lack of understanding as to the pathways available to the acute clinicians for making a referral/seeking advice from the Specialist Eating Disorder Service ie the Willows.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the role and remit of the Mental Health Liaison Team
Wider context from the report “1) There was a lack of understanding between the Acute Trust clinicians and the Mental Health Trust as to the role of the Mental Health Liaison Team. Clarity is required as to whether the MHLT when asked to review a patient by the acute clinicians are reviewing so as to (i) make a diagnosis of an eating disorder or (ii) assess and assist in the consideration as to whether the Mental Health Act can be used to treat someone if they are refusing treatment.
” 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 Share the ratified policy with Pennine Care NHS Foundation Trust for cross-trust review and suggested revision.
Verbatim wording from the response “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.” Source location Response from Northern Care Alliance 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 Implement and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.
Verbatim wording from the response “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.” Source location Response from Northern Care Alliance 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 existing policy sufficiently clarifies responsibilities and referral pathways for adult patients with eating disorders across the Trusts.
Verbatim wording from the response “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.” Source location Response from Northern Care Alliance NHS Foundation Trust
Open published response
Concerns raised 16 Under-reporting of eating disorder deaths to the coroner View source Lack of clear responsibility for monitoring and co-ordinating community eating disorder care View source Absence of an acute hospital liaison psychiatry service View source Poor and inaccurate compilation of clinical documentation View source Poor nursing care for patients with eating disorders View source Lack of dissemination and understanding of MARSIPAN guidance among medical professionals View source Lack of appropriate investigation and learning from eating disorder deaths View source Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs View source Failure to conduct incident reviews of referral failures View source Failure to closely monitor food intake and purging behaviours View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source Failure to maintain nutrition and fluid charts View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nichola Jane Lomax · 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
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-reporting of eating disorder deaths to the coroner
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care .
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders . It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an acute hospital liaison psychiatry service
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital .
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor and inaccurate compilation of clinical documentation
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor nursing care for patients with eating disorders
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care . There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report “1) Inadequate Training of doctors and other medical professionals re eating disorders
For National / NCA / Royal College of Psychiatrists
Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient .
Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground .
Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate investigation and learning from eating disorder deaths
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths . This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital.
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester . However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct incident reviews of referral failures
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients
Wider context from the report “5) Community Monitoring of patients with an Eating Disorder
For BURY CCG / NATIONAL / ICB/ GMHSCP
There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community . The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report
18 Oct 2021 Mohammed Abdus Salem · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Insufficient rigour in root cause analyses 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
Mohammed Abdus Salem · 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
Mohammed Abdus Salem, who had chronic myelomonocytic leukaemia, was admitted to hospital after his condition deteriorated and died after being found unresponsive on 1 April 2021. A further intended dose of Rasburicase was not administered on 1 April despite high urate levels; it was considered more likely than not that giving it would have prolonged his life by up to 48 hours. The Root Cause Analysis did not examine the factors behind the omitted dose or its consequences, raising concerns about the rigour of the review and organisational learning from the death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient rigour in root cause analyses
Wider context from the report “1. The Root Cause Analysis (RCA) undertaken by the Northern Care Alliance identified that a dose of Rasburicase had not been administered on 1 April 2021 however it did not consider any of the factors that gave rise to that omission or its consequences . My concern is that the RCA fell short of the required standard of rigour which leaves residual questions as to organisational governance standards and learning from death .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make pharmacy input mandatory in root-cause analyses whenever medication issues are identified, ensuring objective and expert review.
Verbatim wording from the response “Issue: The need to ensuring robust address of any medication issues in all RCAs.” Source location 2021-0348-Response-from-Northern-Care-Alliance-NHS-Foundation-Trust_Published
Open published response
18 Jun 2021 Leslie Horsfield · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Lack of prompts in admissions assessment tools to ask about previous choking episodes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie Horsfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leslie Horsfield, aged 84, was admitted to hospital with a cough and worsening breathlessness and died on 3 October 2020 after vomiting and becoming unresponsive. A post-mortem found food material blocking his left bronchus, and the reported cause of death was asphyxiation from vomited stomach contents. The principal concern was that the admissions assessment tool did not prompt assessors to ask about previous choking episodes, creating a risk that relevant information would be missed.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prompts in admissions assessment tools to ask about previous choking episodes
Wider context from the report “The absence of any prompt in the admissions assessment tool which reminds assessors to ask patients about previous choking episodes creates a risk that relevant information is missed from the assessment and places the onus on the patient to volunteer information which they may not appreciate is relevant to the assessment
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the nursing admission proforma to ask whether patients have previously experienced choking episodes during the EPR rollout.
Verbatim wording from the response “Having considered the matter further, I would like to provide you with assurance that as part of our Electronic Patient Record (EPR) Programme roll-out across the North East Sector, the nursing admission proforma will be updated to ask whether the patient has previously experienced any choking episodes. The timeframe for implementation of EPR across Pennine is Spring 2023.” Source location 2021-0215-Response-from-Northern-Care-Alliance_Published
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 swallowing questions are considered adequate to manage choking risk despite lacking a specific question about previous choking episodes.
Verbatim wording from the response “Having discussed this with senior nursing colleagues within the Trust, it is however maintained that the nursing admission proforma provides the assessor with the ability to adequately explore a patient’s swallowing capability. Whilst the nursing assessment does not ask a specific question in relation to previous episodes of choking, the assessment does clearly question patients in relation to any problems with eating and drinking, the need for modified dietary consistency, or anything else to prompt a referral to Speech and Language Therapy.” Source location 2021-0215-Response-from-Northern-Care-Alliance_Published
Open published response
3 Feb 2021 Mrs. Monica McCormick · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to complete suspected cancer upgrade forms for malignancy-labelled pathology specimens View source Failure to communicate pathology reports to general practitioners at hospital discharge View source Failure to consider medical records at hospital discharge View source Failure to consider patient records when outpatient appointments are cancelled View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs. Monica McCormick · 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. Monica McCormick developed a colonic perforation in October 2019 and underwent emergency surgery, after which pathology identified adenocarcinoma. The diagnosis was not communicated to her or her general practitioner until April 2020, following cancelled outpatient appointments, and the cancer had then spread to the liver and abdominal cavity. She died at home on 24 May 2020; the concerns included failures to follow up the pathology result, review medical records, communicate the diagnosis, and make an earlier referral for adjuvant chemotherapy.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete suspected cancer upgrade forms for malignancy-labelled pathology specimens
Wider context from the report “Evidence was heard that the pathology sample was not followed up because despite labelling the specimen to include the word malignancy the operating clinicians did not complete an online “suspected cancer upgrade form” at the time of surgery .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate pathology reports to general practitioners at hospital discharge
Wider context from the report “2. The pathology report was not communicated to her general practitioner at the time she was discharged from hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider medical records at hospital discharge
Wider context from the report “1. Appropriate consideration was not given to the deceased’s medical records at the time of her discharge from hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider patient records when outpatient appointments are cancelled
Wider context from the report “3. Appropriate consideration was not given to her records at the time that each outpatient appointment was cancelled
” Open source report
Concerns raised 11 Failure to ensure pharmacists and clinical teams apply consistent ferritin-checking expectations View source Lack of regular independent peer review of coronial autopsy reports and processes View source Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses View source Shortage of staff within the Tissue Viability Nurse team View source Failure to produce accurate and satisfactory coronial post-mortem reports View source Inadequate emergency response arrangements for out-patient iron infusions View source Failure to obtain ferritin levels for anaemia management View source Insufficient access to appropriate dressings for severe pressure sores View source Unclear Royal College of Nursing instructions on continuous observation during iron infusions View source Unclear instructions on continuous observation during iron infusions View source Failure to record pharmacist-clinician discussions and advice View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Byron · 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
Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure pharmacists and clinical teams apply consistent ferritin-checking expectations
Wider context from the report “2. In addition there was no evidence that on the 30th December or the 9th January 2017 the pharmacist checked Mr Byrons ferritin level . The Court heard from the Clinical lead pharmacist that he would expect this to be done. There was a clear difference between the advice and expectations of the pharmacist and the Clinical 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular independent peer review of coronial autopsy reports and processes
Wider context from the report “3. It is noted there is no regular (independent) peer review of coronial autopsy reports and processes in order to maintain consistency of agreed standards, governance and accountability as was advised within the 2006 National Confidential Enquiry into Patient Death and Outcome (NCEPOD) and reiterated within the Hutton review of forensic pathology of England and Wales in 2015.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses
Wider context from the report “1. The Court heard evidence that since the death of Mr Byron the District Nursing and Tissue Viability Nurses (TVNs) are now managed as part of the Northern Care Alliance and are jointly located. However there is no documented policy for the referring of patients from the District Nurses to the TVNs . “Unofficial” referrals could occur by way of conversations within the office and there is no policy to ensure these are recorded in writing and recorded in the patients notes . The Court heard evidence that such a referral was thought to have occurred in September 2016 but this was not documented anywhere.
2. Likewise if a referral is sent by email there no instruction to staff that such email must be uploaded into the patients records in order for it to be clearly seen by all workers that the patient has been referred.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of staff within the Tissue Viability Nurse team
Wider context from the report “3. Shortage of staff. One of the reasons there was a lack of continuity in the care of Mr Byron was the shortage of staff and the increased workload on the remaining staff. The Court was advised there remains a shortage of staff within the Tissue Viability Nurse 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce accurate and satisfactory coronial post-mortem reports
Wider context from the report “1. The quality of the post mortem examination report produced by ████████ was wholly unsatisfactory and proven inaccurate . This meant both the bereaved family and the Trust were initially provided with an inaccurate medical cause of death. As a direct consequence the ability to learn lessons in order to prevent future deaths was not captured in a timely manner. It was not until the Coroner obtained a report from ████████ in 2018 that anaphylaxis was offered as a potential cause of death. Even then, the Court was left having to consider the totality of the evidence and it was not until the inquest that a finding of fact as to the medical cause of death was made.
2. It should be noted the quality of ████████ post mortem practice has been and remains questionable in over 20 Inquests within the North Manchester Coronal area. This is not an isolated case. In this particular case there was clear evidence that the post mortem failings directly impacted on potential lack of clinical learning to prevent future deaths.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate emergency response arrangements for out-patient iron infusions
Wider context from the report “5. In addition for out-patients who may receive an iron infusion the Court received evidence that they would be handed a buzzer . The Court would question how this would be of use should a patient suffer a cardiac arrest such occurred with Mr Byron. Points 4 and 5 link into the Regulation 28 to the Royal College of Nursing 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain ferritin levels for anaemia management
Wider context from the report “1. In this case the Trust Guideline ‘Patient Blood Management of Medical Patients’ sets out the Pathway for the Management of Anaemia. In addition to this Trust documents there is NICE guidance for Anaemia – iron deficiency (revised 2018). Both of these documents include as a key factor the obtaining of ferritin levels , albeit the question as to the interpretation of such results will be dependant on the patients presenting condition. On the 30th December 2016 no sample was taken to check the ferritin levels .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient access to appropriate dressings for severe pressure sores
Wider context from the report “1. The Court heard evidence that at times there was a lack of appropriate dressings in order to treat Mr Byrons infected pressure sores. The Court heard evidence the District Nurses cannot order more than two weeks worth of dressings for any individual patient and cannot hold extra stock . In Mr Byrons case due to the severity and location of the pressure sores there were times when he used more dressings, especially if they came away from the wounds. This could lead to a shortage and meant him having to wait for dressings . In someone with severe pressures sores the requirement to have access to the appropriate dressings is important. The Court heard this instruction regarding the ordering of dressings is governed by the Clinical Commissioning Group.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear Royal College of Nursing instructions on continuous observation during iron infusions
Wider context from the report “1. In the most recent guidance from the Royal College of Nursing dated May 2019, “Iron Deficiency and Anaemia in Adults” the instruction to nurses is for them to “observe the patient for 30 minutes”. The Court heard evidence from the Divisional Director of Nursing for the Northern Care Alliance who told the Court, in his view this instruction to nurses is unclear . This instruction was felt to be open to interpretation as to whether this means nurses should physically remain with the patient constantly for 30 minutes . If this is what is meant then it was suggested the instruction could be made more specific.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear instructions on continuous observation during iron infusions
Wider context from the report “4. The Court heard the Trust Guideline ‘Patient Blood Management of Medical Patients’ indicated the patient was to be observed for 30 minutes during the administration of the iron infusion. Due to a lack of recording the nurse who administered the iron infusion on the 30th December 2017 could not be identified. The nurse on the 9th January 2017 gave evidence to the Court that this was the first time she had administered an iron infusion and she was advised by the Sister to “treat it as a blood transfusion” whereby his observations were taken before and immediately after commencement of the infusion and observations taken every 15 minutes. Hence Mr Byron was left alone during the administration of the iron infusion. The Court heard the policy was unclear as to whether it meant nurses had to remain with the patient constantly for 30 minutes .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record pharmacist-clinician discussions and advice
Wider context from the report “3. The Court heard of discussions which take place between the Pharmacists and clinicians. These can take place at times when the pharmacist is off the ward. In these circumstances there is no ability for the pharmacist to record such discussions . There was no record anywhere of any discussions on the 30th December 2016 or the 9th January 2017 and any such advice provided, so there was no way of confirming if such conversations had taken place.
” Open source report
16 Oct 2019 Victor James Hall · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Failure of pharmacy-to-ward medication transfer procedures to require receipt checks against packaging, labelling and prescription charts View source Failure to contemporaneously document medication packaging, labelling and prescription checks View source Failure to check medication packaging and labelling against the prescription chart before administration View source Phosphate Polyfusor product design failing to distinguish the medication clearly View source Insufficient training, auditing, supervision and monitoring of nursing and pharmacy staff on medication checking controls View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Victor James Hall · 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
Victor James Hall died at Salford Royal Hospital on 29 June 2018 after being admitted with shortness of breath and an exacerbation of chronic obstructive pulmonary disease. He was mistakenly administered Phosphate Polyfusor instead of prescribed sodium bicarbonate after dispensing, pharmacy checking and ward checking errors, although the post-mortem and toxicology evidence concluded that the medication error played no role in his death. Concerns were raised about the similar Polyfusor product design and about medication-checking, recording, dispensing, training and supervision procedures.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of pharmacy-to-ward medication transfer procedures to require receipt checks against packaging, labelling and prescription charts
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward . Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contemporaneously document medication packaging, labelling and prescription checks
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check medication packaging and labelling against the prescription chart before administration
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label . Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Phosphate Polyfusor product design failing to distinguish the medication clearly
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design .
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same .
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training, auditing, supervision and monitoring of nursing and pharmacy staff on medication checking controls
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor completion of medicines-safety training by nursing staff on Ward H2.
Verbatim wording from the response “| ████████ | 29th February 2020
Analysing near miss data to identify common dispensing errors and introducing on-going communication of this to staff. | ████████ | 29th February 2020
Reviewing the accuracy checking test to incorporate a wider range of medications. | ████████ | 29th February 2020
Monitoring of compliance of medicines safety training completed by nursing staff on Ward H2. | ████████ | Commenced
Monitoring of medicine safety incidents on ward H2 | ████████ | Commenced
Policy to be published about the process to follow when involved in a medicines safety incident. | ████████ | 29th February 2020
All nursing staff to be made aware that there are many different types of Polyfusor products. In order” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update accuracy-checking procedures to require a second check for all intravenous fluids.
Verbatim wording from the response “Action | Action Lead | Completion By
Updating the accuracy checking procedure which will incorporate a second check for all intravenous fluids. | ████████ | 31st December 2019
Introducing an electronic sign off to indicate that key procedures have been read and understood by relevant staff. | ████████ | 31st December 2019
Reviewing the number of items required to complete dispensing and accuracy checking logs during induction. | ████████ | 31st December 2019
Introducing a formal revalidation procedure for staff involved in dispensing errors | ████████ | 29th February 2020
Introducing a recurrent accuracy checking log for all accuracy checkers to ensure competence. | ████████ | 29th February 2020
Identifying formal supervisory duties and responsibilities in the dispensary.” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement closed-loop dispensing by linking electronic prescribing, pharmacy dispensing and robotic systems.
Verbatim wording from the response “| ████████ | 31st January 2020
Reviewing the layout of the dispensary with the aim of separating the areas used for different parts of the dispensing process and improving the flow of work. | ████████ | 29th February 2020
Implementing “closed loop dispensing” (linking the electronic prescribing system to the pharmacy dispensing system and robot) with the aim of reducing dispensing errors and improving efficiency and therefore reducing the number of staff needed in the dispensary. | ████████ | 30th June 2020” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure Ward H2 nursing staff comply with mandatory medicines-safety training and monitor their compliance.
Verbatim wording from the response “• Deborah Hindle, Deputy Director of Nursing for the Integrated Care Division will ensure that all nursing staff on ward H2 are compliant with their medicines safety mandatory training. Deborah Hindle will monitor medicines safety mandatory training and ensure all staff are compliant. Weekly senior nurse walkabouts will include ward H2, where observations will be undertaken of nursing medication/fluids dispensary checking procedure.” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the accuracy-checking test to cover a wider range of medications.
Verbatim wording from the response “| ████████ | 29th February 2020
Analysing near miss data to identify common dispensing errors and introducing on-going communication of this to staff. | ████████ | 29th February 2020
Reviewing the accuracy checking test to incorporate a wider range of medications. | ████████ | 29th February 2020
Monitoring of compliance of medicines safety training completed by nursing staff on Ward H2. | ████████ | Commenced
Monitoring of medicine safety incidents on ward H2 | ████████ | Commenced
Policy to be published about the process to follow when involved in a medicines safety incident. | ████████ | 29th February 2020
All nursing staff to be made aware that there are many different types of Polyfusor products. In order” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange staff feedback sessions on improvements to clinical checking, dispensing and accuracy-checking processes.
Verbatim wording from the response “Action | Action Lead | Completion By
Preventing staff entering the dispensary unless they have a relevant reason to be in there and so minimise the risk of interruption. This will be enforced with signage and staff awareness at daily huddles. | ████████ | 31st January 2020
Introducing library conditions within the dispensary. | ████████ | Commencing with immediate effect.
Changing the exit route (after 5pm) from the department which is currently located next to the accuracy checking area. Staff will exit the department via the pharmacy reception exit, preventing staff using the dispensary as a thoroughfare. | ████████ | 31st January 2020
Arranging feedback sessions for all staff to highlight elements of the clinical check, dispensing and accuracy check processes that need to be improved. Staff will be made aware of this at daily huddles.” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce formal revalidation for staff involved in dispensing errors.
Verbatim wording from the response “Action | Action Lead | Completion By
Updating the accuracy checking procedure which will incorporate a second check for all intravenous fluids. | ████████ | 31st December 2019
Introducing an electronic sign off to indicate that key procedures have been read and understood by relevant staff. | ████████ | 31st December 2019
Reviewing the number of items required to complete dispensing and accuracy checking logs during induction. | ████████ | 31st December 2019
Introducing a formal revalidation procedure for staff involved in dispensing errors | ████████ | 29th February 2020
Introducing a recurrent accuracy checking log for all accuracy checkers to ensure competence. | ████████ | 29th February 2020
Identifying formal supervisory duties and responsibilities in the dispensary.” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a recurring accuracy-checking log for all accuracy checkers to monitor competence.
Verbatim wording from the response “Action | Action Lead | Completion By
Updating the accuracy checking procedure which will incorporate a second check for all intravenous fluids. | ████████ | 31st December 2019
Introducing an electronic sign off to indicate that key procedures have been read and understood by relevant staff. | ████████ | 31st December 2019
Reviewing the number of items required to complete dispensing and accuracy checking logs during induction. | ████████ | 31st December 2019
Introducing a formal revalidation procedure for staff involved in dispensing errors | ████████ | 29th February 2020
Introducing a recurrent accuracy checking log for all accuracy checkers to ensure competence. | ████████ | 29th February 2020
Identifying formal supervisory duties and responsibilities in the dispensary.” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement closed-loop medication administration using electronic barcode scanning of patients and medications.
Verbatim wording from the response “Action | Action Lead | Completion By
Implementing “closed loop medication administration” (electronic barcode scanning of patients and medications) to ensure that patient’s receive the right drug at the correct dose by the right route at the intended time. This will indicate to nursing staff (at the point of administration rather than the point of receipt) that the prescribed medication has been correctly sourced. | Digital Team | 30th June 2020” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly senior-nurse walkabouts on Ward H2, observing nursing medication and fluid dispensing-checking procedures.
Verbatim wording from the response “• Deborah Hindle, Deputy Director of Nursing for the Integrated Care Division will ensure that all nursing staff on ward H2 are compliant with their medicines safety mandatory training. Deborah Hindle will monitor medicines safety mandatory training and ensure all staff are compliant. Weekly senior nurse walkabouts will include ward H2, where observations will be undertaken of nursing medication/fluids dispensary checking procedure.” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure nursing staff recognise different Polyfusor products and check all medication details in full.
Verbatim wording from the response “| ████████ | 29th February 2020
Analysing near miss data to identify common dispensing errors and introducing on-going communication of this to staff. | ████████ | 29th February 2020
Reviewing the accuracy checking test to incorporate a wider range of medications. | ████████ | 29th February 2020
Monitoring of compliance of medicines safety training completed by nursing staff on Ward H2. | ████████ | Commenced
Monitoring of medicine safety incidents on ward H2 | ████████ | Commenced
Policy to be published about the process to follow when involved in a medicines safety incident. | ████████ | 29th February 2020
All nursing staff to be made aware that there are many different types of Polyfusor products. In order” Source location 2019-0482-Response-by-Northern-Care-Alliance-NHs-Trust
Open published response
Concerns raised 3 Failure to establish shared care arrangements or identify an organisation for blood sampling for drug monitoring View source Failure to ensure required blood tests for individuals under specialist secondary care for renal failure View source Failure to communicate referral responses, referral updates and community test requests directly to primary care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Andrew Mellor · 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
John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish shared care arrangements or identify an organisation for blood sampling for drug monitoring
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure required blood tests for individuals under specialist secondary care for renal failure
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure . Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility .
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate referral responses, referral updates and community test requests directly to primary care
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly , with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider .
” Open source report
26 Sep 2018 John Waite · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Lack of national guidelines for central venous catheter removal View source Electronic clinical notes permitting alteration of author times View source Failure to provide constant visual observation after central venous catheter removal 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
John Waite · 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
John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.
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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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for central venous catheter removal
Wider context from the report “iv. There are no national guidelines in relation to the removal of central venous catheters, particularly temporary central venous catheters for haemodialysis. The evidence at the Inquest confirmed that the Secretary of State, the Renal Association, the British Renal Society and the Intensive Care Society would be appropriate organisations to consider the issue of a national policy, protocol and guidance relating to the removal of central venous catheters.
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Electronic clinical notes permitting alteration of author times
Wider context from the report “4. I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note . The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide constant visual observation after central venous catheter removal
Wider context from the report “ii. The Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters in existence within the Salford Royal NHS Foundation Trust at the time of the death included the fact that pressure should be applied for approximately 5 minutes after removal of the catheter or until bleeding has stopped and a patient should lie flat or supine for 30 minutes after removal of the catheter (if medically safe to do so). The guidelines did not state that a patient requires visual observation for a period of time following the removal of the catheter.
iii. Following the death of the Deceased the Salford Royal NHS Foundation Trust has taken action to address the concerns in relation to the Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters, together with the ongoing training of staff who undertake the removal of catheters and the management of rare complications.
A quick reference guide has been issued to staff by the Hospital in relation to the removal of catheters at the Hospital. The guide requires the patient to remain supine for 30 minutes post removal of the catheter with further bed rest for 2 hours post removal and a visual inspection of the dressing every 5 minutes during the period of 1 hour following the removal. However, the guide does not require constant visual observation for a period of time following the removal of the catheter.
The evidence at the Inquest was that, if there is haemorrhage following the removal of a catheter, blood loss could amount to 200mls every minute so that in the period of 5 minutes between each 5-minute inspection of the dressing, advised by the guidance, one litre of blood could be lost, which could lead to death.
The evidence at the Inquest was that a period of constant visual observation is required for a period of up to one hour following the removal of a catheter to reduce the risk of blood loss rather than simply monitoring by inspecting the dressing every 5 minutes for that period of time.
” Open source report
12 Apr 2018 James Sheffield · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to ensure immediate availability and readiness for use of patient-owned medical equipment after internal transfers View source Lack of a system to ensure that patient-owned medical equipment remains with patients during internal hospital transfers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James Sheffield · 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
James Sheffield suffered a cardio-respiratory arrest on 12 July 2016 after surgery following an accidental fall and died on 17 July 2016. The report identified concerns about the absence of an established system to ensure that patient-owned CPAP equipment remained with patients during internal hospital transfers and was immediately available and ready for use. The report stated that the missing CPAP machine did not have a bearing on the outcome.
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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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediate availability and readiness for use of patient-owned medical equipment after internal transfers
Wider context from the report “3. However, the evidence that I heard revealed that there was no established system in place to ensure that such a piece of important medical equipment would remain with the patient in the event of transfer of that patient within the hospital from differing wards, units or departments;
4. Whilst I heard evidence that a comprehensive “Report following investigation” had been conducted by Salford Royal Hospital, facilitated by their Governance Manager, in which there was correctly identified the necessary potential root causes, conclusions and sharing of lessons, proposed monitoring mechanisms, ward to ward transfer documents and electronic record systems that had been put in place – nevertheless, the evidence that I received suggested that there were outstanding protocols and/or policies to be implemented to ensure that following an internal transfer, patient owned medical equipment such as the “CPAP” machine should not only be moved with that patient, but specific measures taken to ensure that it was both immediately available and ready for use to enable the patient to self-care upon completion of the transfer .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to ensure that patient-owned medical equipment remains with patients during internal hospital transfers
Wider context from the report “3. However, the evidence that I heard revealed that there was no established system in place to ensure that such a piece of important medical equipment would remain with the patient in the event of transfer of that patient within the hospital from differing wards, units or departments ;
4. Whilst I heard evidence that a comprehensive “Report following investigation” had been conducted by Salford Royal Hospital, facilitated by their Governance Manager, in which there was correctly identified the necessary potential root causes, conclusions and sharing of lessons, proposed monitoring mechanisms, ward to ward transfer documents and electronic record systems that had been put in place – nevertheless, the evidence that I received suggested that there were outstanding protocols and/or policies to be implemented to ensure that following an internal transfer, patient owned medical equipment such as the “CPAP” machine should not only be moved with that patient , but specific measures taken to ensure that it was both immediately available and ready for use to enable the patient to self-care upon completion of the transfer.
” Open source report
26 Sep 2017 Rodney Hampshire · Prevention of Future Deaths report Manchester West
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Concerns raised 1 Lack of monitored beds on surgical wards 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
Rodney Hampshire · 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
Rodney Hampshire underwent bowel surgery at Salford Royal Hospital on 12 May 2017 and was transferred from intensive care to a surgical ward on 15 May. He suddenly deteriorated and sustained a cardiac arrest on 16 May. The substantive concern was a review of whether monitored beds on surgical wards could potentially save lives, although there was no evidence that this would have affected the outcome in this case.
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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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of monitored beds on surgical wards
Wider context from the report “During the inquest evidence was given that the division of surgery at Salford Royal Foundation Trust is conducting a review examining the benefits of having a small number of monitored beds on the surgical wards such as the ward to which Mr Hampshire had been transferred. Whilst there was no evidence that this would have affected the outcome in this case, evidence was given that monitored beds of the type envisaged would potentially save lives .
” 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 Establish an Extended Recovery Unit for postoperative patients, providing up to 48 hours of level 1 monitoring by experienced medical and nursing teams.
Verbatim wording from the response “Extended Recovery Unit Model” Source location 2017-0236-Response-by-Salford-Royal-NHS-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 Operate an eight-bed H6 Monitored Unit providing level 1 postoperative monitoring and enhanced nursing support.
Verbatim wording from the response “H6 Monitored Unit” Source location 2017-0236-Response-by-Salford-Royal-NHS-Trust
Open published response
6 Feb 2017 Natalie Ann Thornton · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of a formal pump agreement View source Inadequate monitoring and review of blood sugar levels and pump-generated data View source Inconsistent national support for insulin pump users View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Natalie Ann Thornton · 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
Natalie Thornton, who had longstanding brittle type 1 diabetes and related complications, began insulin pump therapy in December 2014. On 18 January 2015 she became unwell, collapsed, and died; the inquest concluded that the medical cause of death was diabetic ketoacidosis. Concerns were raised about the adequacy of monitoring and review of blood sugar data after the pump was introduced, including that trends were not analysed, and about variable national support for insulin pump users.
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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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal pump agreement
Wider context from the report “1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and review of blood sugar levels and pump-generated data
Wider context from the report “1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent national support for insulin pump users
Wider context from the report “2. From the evidence given by the expert Consultant ████████ it would appear that the level of support for insulin pump users nationally is variable . Whether the need for consistency and minimum standards should be addressed by Regional Centres of Excellence would be a matter for the Department to consider.
” Open source report
16 Jul 2015 Stanley Oliver · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of out-of-hours availability of GI Radiologists to perform percutaneous cholecystostomy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanley Oliver · 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
Stanley Oliver, aged 85, died at Salford Royal Hospital after being admitted with abdominal pain and a perforated gall bladder. A drainage procedure was not performed over the weekend because there was no out-of-hours rota for GI Radiologists, and the report raised concerns about the availability, communication arrangements and training needed for urgent procedures of this kind.
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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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours availability of GI Radiologists to perform percutaneous cholecystostomy
Wider context from the report “1. During the Inquest evidence was heard that:
i. There was no on call rota for a GI Radiologist to perform a percutaneous cholecystostomy out of hours and particularly over a weekend. The Hospital Trust indicated that a risk had been identified in relation to the unavailability of GI Radiologists out of hours and the Hospital that managed the risk by allowing the GI Radiologist to be contacted out of hours but the Trust accepted that there was no provision for the Radiologist to be available out of hours.
ii. The Consultant Surgeon gave evidence at the Inquest that availability of a GI Radiologist to perform a percutaneous cholecystostomy was critical to the management of a patient and he raised concerns that there would be a risk to life if a percutaneous cholecystostomy could not be performed out of hours, either overnight or over a weekend.
iii. I accepted evidence at the Inquest that the Salford Royal NHS Foundation Trust were considering actions to make GI Radiologist available out of hours and to establish a system for any Radiologist to contact a GI Radiologist our of hours for procedures to be conducted out of hours. However there was no confirmation that an out of hours on call rota was being considered for GI Radiologists either within the Salford Royal NHS Foundation Trust or for a rota relate to a wider area covering several other hospitals on the basis that an available Radiologist could travel to different hospitals to carry out a necessary procedure out of hours.
iv. Evidence was given at the Inquest that the unavailability of GI Radiologists was not limited to Salford but was a national problem in that there were very few out of hours on call rotas for GI Radiologists in hospitals in the United Kingdom.
It was accepted that a perforated gall bladder was a recognised condition, which occurred on a regular basis as an emergency presentation to hospital. In some cases surgical intervention would not be appropriate and an alternative treatment plan would involve the insertion of a percutaneous cholecystostomy drain or a drain to be inserted outside the gall bladder, both of which would require insertion by a GI Radiologist.
v. The evidence raised concerns that there is a risk of future deaths will occur unless action is taken to review the above issues.
” 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 Work with Greater Manchester acute provider trusts to share interventional radiology expertise and improve equitable seven-day access.
Verbatim wording from the response “The issues highlighted by this case reflect a national shortage of Consultant Interventional Radiologists and are not particular to SRFT with no acute provider Trust in Greater Manchester being able to provide a comprehensive out of hours IR service. We recognise our role in making sure that access to IR is equitable across 7 days not just at SRFT but more widely across GM and we will be working with the other acute provider Trusts across Greater Manchester to ensure expertise is shared.” Source location S-Oliver-Response
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 Develop a 1-in-6 non-vascular interventional radiology rota at SRFT to provide seven-day Consultant-level cover by April 2016.
Verbatim wording from the response “The medium term plan is to develop a 1 in 6 non-vascular intervention rota at SRFT to ensure that there is 7 day cover at Consultant level by April 2016. This will involve a number of detailed actions which are described further within the action plan below. Whilst this has” Source location S-Oliver-Response
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 Update the Standard Operating Procedure to reflect weekend non-vascular interventional radiology arrangements.
Verbatim wording from the response “The short term plan is to continue to use the SRFT ad hoc service with additional support from Central Manchester NHS Foundation Trust (CMFT). CMFT plan to have a weekend non-vascular intervention service from October 2015 and have agreed that they will support our service and perform cases that we are not able to safely perform at SRFT at weekends. A Standard Operating Procedure (SOP) has been updated to reflect this change (Appendix 2) and further details can be found in the action plan below.” Source location S-Oliver-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A comprehensive out-of-hours interventional radiology service cannot currently be delivered because of a national shortage of skilled consultant radiologists.
Verbatim wording from the response “As with many NHS acute provider Trusts across the country, the IR service at SRFT is currently unable to deliver a comprehensive out of hours (OOH) service.” Source location S-Oliver-Response
Open published response
22 Sep 2014 Martin Leslie Dean · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to ensure that visitors wash their hands before entering Critical Care Wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Martin Leslie Dean · 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
On 13 December 2013, Martin Leslie Dean suffered an intracerebral haemorrhage at home and was transferred to Salford Royal Hospital, where a shunt and feeding tube were inserted. The inquest concluded that he died as a consequence of a naturally occurring intracerebral haemorrhage together with a complication of necessary treatment. Evidence raised concerns that visitors to the Critical Care Ward were not washing their hands on entry, despite hand washing being identified as the most effective single precaution against infection.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that visitors wash their hands before entering Critical Care Wards
Wider context from the report “During the Inquest evidence was given that a number of visitors to the Critical Care Ward where Martin Leslie Dean was a patient were not washing their hands on entering the ward . Further evidence stated that the most effective single precaution that could be taken to prevent infection was hand washing. The evidence continued by revealing that it would be possible to station volunteers at the entrances to wards particularly at the entrances to Critical Care Wards where patients might be especially susceptible to infection in order to ensure that visitors did not enter the wards without washing their hands. As volunteers could be used for this function, it was stated that it would be a precaution that could be achieved at little or no cost.
” Open source report
9 Sep 2013 Martin Daffydd Barker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby View source Lack of ambulance crew access to coded hospital entrance keypads View source Failure to maintain continuous staffing of resuscitation receptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Martin Daffydd Barker · 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
Martin Daffydd Barker became unwell after taking MDMA at a large event on 9 December 2012 and was transported to Salford Royal Hospital, where he was pronounced deceased; his cause of death was confirmed as MDMA toxicity. Concerns included the absence of clear guidance for independent medical providers to pre-alert hospitals about critically ill incoming patients, resulting in the hospital not being prepared for his arrival, and difficulties accessing the resuscitation unit overnight.
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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national guidance and routing for independent providers to pre-alert hospitals and place them on standby
Wider context from the report “1. There appears to be no national guidance on how independent national providers of medical services (particularly those covering large scale public events) can put NHS hospitals on standby for incoming urgent patients , something which is normal procedure for the regional ambulance services.
2. There is confusion as to whether the independent providers should place a call to the regional ambulance services who would then act as “gatekeeper” in forwarding this information to the respective hospital.
3. Without clear guidance there is a risk that the most critically ill people who are being transported to hospital are at risk as the hospitals have received no pre-alert, have not had the opportunity to place teams on standby and are not expecting their arrival .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance crew access to coded hospital entrance keypads
Wider context from the report “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to .
” 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 Northern Care Alliance NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuous staffing of resuscitation receptions
Wider context from the report “4. In certain hospitals at particular times i.e. overnight this problem is exacerbated by the fact that the resus reception is not manned constantly and this may cause delays in ambulance crew gaining access especially if the entrance has a coded key pad which they also do not have access to.
” Open source report
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Addressed to Northern Care Alliance NHS Group, now represented here by Northern Care Alliance NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations