Concerns raised 5 Delays or failures in delivery of ED discharge summaries View source Failure to supply ED discharge summaries to patients View source Lack of quality assurance auditing for ED discharge summaries View source Failure to review radiology reports received after ED discharge View source Inadequate information in ED discharge summaries View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David MARRIOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Marriott died at City Hospital, Nottingham, on 18 July 2025 from metastatic lung cancer diagnosed in May 2025. The report identified missed opportunities to arrange a follow-up chest x-ray after his February 2024 Emergency Department visit, including failures to follow guidance and to review radiology reports received after discharge. It also raised concerns about inadequate discharge summaries, lack of quality assurance, and failure to provide summaries to patients.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays or failures in delivery of ED discharge summaries
Wider context from the report “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients
I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such.
I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning.
I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient.
The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified?
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supply ED discharge summaries to patients
Wider context from the report “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients
I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such.
I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning.
I am further concerned that ED discharge summaries are not supplied to patients . If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing . Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic . Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient.
The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified?
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of quality assurance auditing for ED discharge summaries
Wider context from the report “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients
I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such.
I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning .
I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient.
The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified?
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review radiology reports received after ED discharge
Wider context from the report “2. A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED
The Emergency Department regularly arrange chest x-rays for patients. Often, the ED Consultant will review the x-ray image in order to inform their management plan, prior to the radiology report being issued. In many instances, the patient will have been discharged from ED prior to the radiology report being made available on the system. I understand this is an acceptable and reasonable practice in ED departments given the high patient footfall, the need to discharge efficiently, and the inevitable time lag between imaging and reporting of non-urgent x-rays.
However, of significant concern, is the fact that when the radiology report arrives after the patient has been discharged from ED, the requesting clinician is not required to review the report . In fact, no-one reviews the report to see whether it contains information that should alter the management plan .
Here, the radiologist made a clear recommendation that a follow up chest x-ray should be arranged as he could not rule out something sinister under the infection. The issue around ought to have been considered by the requester, or another clinician on duty, as it would have altered David’s management plan.
I am concerned that this is a long-standing issue at NUH.
In 2016, the coroner issued a prevention of future death report on this topic. The coroner was assured that the introduction of nervecentre would prevent this situation.
The SJCR in this case said, “There is a system failing here regarding review of images [sic reports] once a patient has been discharged from ED . This is a known issue for which solutions have been proposed, including introducing a results sign off session for ED consultants utilising EDP. The current HoS has not progressed with this solution and sadly therefore, further missed imaging results are likely and similar cases of missed opportunities for intervention are guaranteed”.
It would seem, therefore, that the Trust has been aware of this risk for some time, but has failed to take action to date to seek to mitigate that risk.
I understand that NUH might be an outlier in terms of ED clinicians failing to review electronic results received post-discharge and may well be acting contrary to BMA, RCEM and NHS guidance. The BMA is clear that the ordering clinician has a duty to review test results even where the patient has been discharged (whether bloods, radiology etc) (BMA Acting on electronic test results, 2024). The BMA guidance advises that this task can be delegated within a safe system of work. I understand that many large Trusts have a named Consultant of the day who will review and file all results from the previous day. Others have an IT system that alerts the ordering clinician that the report is ready so they can simply mark it for filing or action. I am not aware of other Trusts locally that simply leave specialist reports and results unread. This is an unsafe practice, and I consider there is a clear risk of future deaths should this practice continue.
It seems to me that the duty to proactively promote patient care does not cease once the patient leaves the department. These reports are important and, in some cases, they will contain information that the ED Consultant missed when reviewing the image in a very busy and demanding environment, or could not have been aware of without reviewing the results.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate information in ED discharge summaries
Wider context from the report “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients
I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on . Often, they contain inadequate or insufficient information , like the one in this case which did not make clear the steps required of the GP . Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such.
I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning.
I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient.
The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified?
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide medical-documentation training, including discharge-summary requirements, through Foundation Doctor induction and Resident Doctor teaching.
Verbatim wording from the response “Education on Medical Documentation
The Trust now provides training on medical documentation as a fixed session in the annual Foundation Doctor Induction and in Resident Doctor teaching, including discharge summaries (applicable Trustwide, not just ED). The materials will be further reviewed and updated prior to the October 2026 delivery in response to this case and will emphasise the importance of robust follow up arrangements and what can reasonably be delivered by community colleagues and what needs to be delivered by NUH (current materials provided in Appendix 7). The Acute Deterioration Improvement Team will also provide an NUH intranet page with the resources.” Source location Response from Nottingham University Hospitals 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 Implement system updates to auto-generate a full clinician summary for appropriate patients discharged directly from ED.
Verbatim wording from the response “In the interim, the Trust has already taken feedback and held discussions with GP colleagues to establish the preferred content of e-posted letters for patients discharged from the Emergency Department back to their care, leading to an agreed template. ED colleagues are completing pharmacy team feedback regarding discharged medication documentation to update the agreed template for improved medicines safety and this is expected to be completed by July 2026.
Nevercentre will then require system updates to include a full clinician summary of attendance which will auto generated for those patients discharged directly from ED (as clinically appropriate).” Source location Response from Nottingham University Hospitals 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 Complete pharmacy feedback and update the agreed ED discharge-letter template to improve medicines documentation.
Verbatim wording from the response “In the interim, the Trust has already taken feedback and held discussions with GP colleagues to establish the preferred content of e-posted letters for patients discharged from the Emergency Department back to their care, leading to an agreed template. ED colleagues are completing pharmacy team feedback regarding discharged medication documentation to update the agreed template for improved medicines safety and this is expected to be completed by July 2026.
Nevercentre will then require system updates to include a full clinician summary of attendance which will auto generated for those patients discharged directly from ED (as clinically appropriate).” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update medical-documentation training materials to emphasise robust follow-up arrangements before October 2026 delivery.
Verbatim wording from the response “Education on Medical Documentation
The Trust now provides training on medical documentation as a fixed session in the annual Foundation Doctor Induction and in Resident Doctor teaching, including discharge summaries (applicable Trustwide, not just ED). The materials will be further reviewed and updated prior to the October 2026 delivery in response to this case and will emphasise the importance of robust follow up arrangements and what can reasonably be delivered by community colleagues and what needs to be delivered by NUH (current materials provided in Appendix 7). The Acute Deterioration Improvement Team will also provide an NUH intranet page with the resources.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish a patient information leaflet explaining pneumonia follow-up requirements and their importance.
Verbatim wording from the response “Discharge Summary
The ED respiratory speciality interface collaborative team are designing a patient information leaflet to be given to those patients being discharged with pneumonia, based on BTS guidance. This will include patient information about the need to see the GP at 6 weeks for follow-up and why this matters. This leaflet will be completed in Draft Format by end of August 2026 and is expected for publication by October 2026 and can be shared if required.” Source location Response from Nottingham University Hospitals 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 Create a multidisciplinary Patient Safety Priority Working Group to address post-discharge ED imaging-result review.
Verbatim wording from the response “The Trust has acknowledged this system gap as one of its key Patient Safety Priorities for 2026-27 and as part of this has created a Patient Safety Priority Working Group to address it. This group is co-ordinated by corporate governance teams and consists of Emergency Medicine and Radiology senior clinicians, Trust digital leads, patient safety specialists and quality improvement support.” Source location Response from Nottingham University Hospitals 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 Create and operate a closed-loop workflow to identify, review, communicate, escalate and track ED imaging results after discharge.
Verbatim wording from the response “The Trust has acknowledged this system gap as one of its key Patient Safety Priorities for 2026-27 and as part of this has created a Patient Safety Priority Working Group to address it. This group is co-ordinated by corporate governance teams and consists of Emergency Medicine and Radiology senior clinicians, Trust digital leads, patient safety specialists and quality improvement support.” Source location Response from Nottingham University Hospitals NHS 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 Manual review of post-discharge radiology reports is not deliverable or sustainable with current systems and capacity.
Verbatim wording from the response “Given the scale of the challenges (average 791 daily attends to NUH ED in Q4), the workload is expected to be high and requires complex cross system working with integration into the current digital systems. Completing this work manually with current systems requires additional resource in significant excess of current capacity and is not deliverable or sustainable.” Source location Response from Nottingham University Hospitals NHS 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 Existing coding processes are considered sufficient to mitigate interim high-risk post-discharge radiology risks while a fuller workflow is developed.
Verbatim wording from the response “In the interim, the current Consensus and ZZZZ coding (used to indicate unexpected malignancy Appendix 5 4288 – Radiology Digital Pick-Up Codes) processes will cover high-risk conditions or potential cancer diagnoses (Appendix 4). Coupled with the actions to address concern 1, this will offer a balanced/mitigated medium-term risk.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
Concerns raised 5 Failure to quarantine relevant medical equipment promptly after clinical events View source Failure to download accurate clinical data from medical devices promptly View source Failure to retain relevant clinical material after clinical events View source Absence of a penicillin allergy de-labelling pathway at NUH View source Failure to complete Datix reports promptly after clinical events View source See 2 more concerns
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. 8
Action
Disseminate interim incident-response messaging and implement a formal communication plan alongside revised policies and SOPs.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Produce and distribute clinical-area visual aids prompting immediate evidence-preservation actions and sources of support.
Stated plannedThe respondent said that this action was planned when they made their response on 13 August 2026. View source
Action
Review opportunities to reduce reliance on non-networked devices and improve immediate access to device information.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Monitor incident-reporting timeliness and investigate the rationale for reporting delays.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Develop and deliver Trust-wide multiprofessional training on prompt reporting, candour, device quarantine, data preservation and related safety processes.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Audit evidence-retention practices one year after policy launch.
Stated plannedThe respondent said that this action was planned when they made their response on 13 August 2026. View source
Action
Strengthen incident-reporting, device-quarantine and evidence-retention policies through governance ratification and publication.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Develop, approve and disseminate SOPs specifying device security, data preservation, storage, testing and manufacturer engagement after device safety events.
Stated plannedThe respondent said that this action was planned when they made their response on 13 August 2026. View source See 5 more actions
×
AI-generated summary
Jennifer Susan BIRCH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jennifer Susan Birch died on 11 April 2025 after suffering anaphylaxis to teicoplanin during the peri-operative period of an elective procedure, resulting in hypoxic brain injury. Concerns included failure to make a 2222 call during the anaesthetic emergency, failures to promptly record and retain evidence after the event, and the absence of a penicillin allergy de-labelling pathway at the Trust.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to quarantine relevant medical equipment promptly after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to download accurate clinical data from medical devices promptly
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines , and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain relevant clinical material after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart .
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces , cardiology medical devices not being retained /quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a penicillin allergy de-labelling pathway at NUH
Wider context from the report “2. (ICB) Roll out of the Penicillin Allergy De-Labelling Pathway
Teicoplanin carries a rare but recognised risk of severe anaphylaxis and reaction occurring in an estimated 0.1-1% of cases. Teicoplanin is often used as an alternative to penicillin for patients who report penicillin allergy. The risk of serious complications is greater in teicoplanin than many other forms of antibiotic (NAP6). It has been described as “an emerging problem in the anaesthetic allergy clinic” (British Journal of Anaesthesia, 2015).
Jen was administered teicoplanin in the peri-operative period because the recommended antibiotic for her elective procedure, Flucloxacillin, is from the same antibiotic family as penicillin, and Jen’s medical records reported an allergy to penicillin in the form of a rash as a baby.
The use of teicoplanin in this case was entirely appropriate given Jen’s allergy warning, but it did expose her to a risk of severe anaphylaxis, which materialised and caused her death. In the months following Jen’s death, some Trusts have rolled out an inpatient initiative to seek to de-label penicillin allergy from patient medical records where risk stratification determines that the patient does not have a true allergy to penicillin. The SPACE study established that up to 10% of the population carries documented penicillin allergy but over 90% of these are inaccurate . False labels have been shown to increase antibiotic resistance, higher surgical site infections, longer hospital stays, as well as exposing patients to unnecessary complications associated with second-line antibiotics.
One local Trust, Doncaster and Bassetlaw NHS Trust, has already rolled out an inpatient PADL pathway. The SPACE study proved it is clinically safe and effective for non-allergy healthcare professionals to use approved risk stratification and direct oral penicillin challenges for low-risk patients, ensuring the burden for this pathway does not impact on the often-small secondary care allergy service.
Does the ICB plan to commission this pathway across all local Trusts? At present, NUH does not offer this pathway.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Datix reports promptly after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event . This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” 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 Disseminate interim incident-response messaging and implement a formal communication plan alongside revised policies and SOPs.
Verbatim wording from the response “v. Communication and Cultural Reinforcement” Source location Response from NUH
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 Produce and distribute clinical-area visual aids prompting immediate evidence-preservation actions and sources of support.
Verbatim wording from the response “iii. Visual Prompts and Frontline Support” Source location Response from NUH
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 opportunities to reduce reliance on non-networked devices and improve immediate access to device information.
Verbatim wording from the response “Planned Improvements and Assurance” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor incident-reporting timeliness and investigate the rationale for reporting delays.
Verbatim wording from the response “Planned Improvements and Assurance” Source location Response from NUH
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 Develop and deliver Trust-wide multiprofessional training on prompt reporting, candour, device quarantine, data preservation and related safety processes.
Verbatim wording from the response “iv. Training and Workforce Development” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit evidence-retention practices one year after policy launch.
Verbatim wording from the response “Planned Improvements and Assurance” Source location Response from NUH
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 Strengthen incident-reporting, device-quarantine and evidence-retention policies through governance ratification and publication.
Verbatim wording from the response “i. Strengthening Policy Framework:” Source location Response from NUH
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 Develop, approve and disseminate SOPs specifying device security, data preservation, storage, testing and manufacturer engagement after device safety events.
Verbatim wording from the response “ii. Introduction of new Standard Operating Procedures (SOPs)” Source location Response from NUH
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 Responsibility for commissioning penicillin allergy de-labelling services rests with the Integrated Care Board, not the Trust.
Verbatim wording from the response “The Trust notes that this recommendation was addressed to the Integrated Care Board (ICB). Penicillin Allergy De-labelling services are not currently commissioned within Nottingham City and Nottinghamshire.” Source location Response from NUH
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 Trust cannot develop penicillin allergy de-labelling services without appropriate commissioning arrangements, workforce capacity and sustainable resourcing.
Verbatim wording from the response “The Trust notes that this recommendation was addressed to the Integrated Care Board (ICB). Penicillin Allergy De-labelling services are not currently commissioned within Nottingham City and Nottinghamshire.” Source location Response from NUH
Open published response
27 Apr 2026 Michael Chadwick · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Failure to provide patients with advice to stop driving and notify the DVLA about cough syncope View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Chadwick · 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
Michael Chadwick died from injuries sustained when the motorcycle he was driving left the road. The principal concern was that, despite repeated reports of cough syncope, he was not advised to stop driving or notify the DVLA, raising concern that similar guidance may not be provided to other patients.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with advice to stop driving and notify the DVLA about cough syncope
Wider context from the report “1. On the multiple occasions that Mr Chadwick was assessed, and his cough syncope brought to the attention of the medical professionals, there was no advice given him to stop driving and to notify the DVLA of his cough syncope, either orally or in writing .
I am concerned that clinicians may fail to provide similar guidance to other patients , which may lead to episodes of syncope whilst driving, with potentially fatal consequences.
” 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 Circulate the transient loss of consciousness guidance to all Trust consultants.
Verbatim wording from the response “1. Review of the NUH guidelines relating to Transient Loss of Consciousness” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trust’s transient loss of consciousness guidance.
Verbatim wording from the response “In response, the following actions are being taken:” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate Medical Director and DVLA driving-advice guidance to consultants and Care Group Governance teams, and publish it on KOHA.
Verbatim wording from the response “2. Guidance from the Medical Director and DVLA circulated to all Consultants and Care Group Governance teams within the Trust to confirm the importance of providing this information to patients.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
14 Oct 2025 David Charles Noel Jones · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to disseminate learning about atypical aortic dissections to relevant clinicians View source Failure to escalate significant clinical changes for review by appropriately senior clinicians View source Failure to carry out Emergency Department morbidity and mortality reviews View source Failure to identify learning from atypical aortic dissection cases View source Potential ineffectiveness of training on atypical aortic dissections View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Charles Noel Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Charles Noel Jones attended hospital after dizziness and was found to have low blood pressure and a low pulse rate. After developing chest pain and sweatiness while mobilising, he was discharged the following day and died later that day from the effects of an aortic dissection. Concerns included the failure to escalate his changing clinical condition to a senior doctor and possible gaps in learning, training and review processes relating to atypical aortic dissections.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate learning about atypical aortic dissections to relevant clinicians
Wider context from the report “1. Whilst reviews were carried out through the Morbidity and Mortality process for two of the departments involved in Mr Jones’ care, one has not been carried out by the Emergency Department, despite concerns raised at inquest by the witness from that team. I am concerned that potential learning, which may make a difference to future patients presenting with atypical aortic dissections, has not been identified or passed on to clinicians within the emergency department and any other relevant departments.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate significant clinical changes for review by appropriately senior clinicians
Wider context from the report “2. Despite Mr Jones’ clinical picture changing whilst in the emergency department, the middle grade doctor reviewing Mr Jones did not alert a senior doctor of the change . I am concerned that training in relation to atypical aortic dissections brought to my attention in evidence at this and a previous inquest, and to my coroner colleague’s attention in inquests they conducted, may not have been ineffective. I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority , and a risk of death from undiagnosed aortic dissections may follow.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out Emergency Department morbidity and mortality reviews
Wider context from the report “1. Whilst reviews were carried out through the Morbidity and Mortality process for two of the departments involved in Mr Jones’ care, one has not been carried out by the Emergency Department , despite concerns raised at inquest by the witness from that team. I am concerned that potential learning, which may make a difference to future patients presenting with atypical aortic dissections, has not been identified or passed on to clinicians within the emergency department and any other relevant departments.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify learning from atypical aortic dissection cases
Wider context from the report “1. Whilst reviews were carried out through the Morbidity and Mortality process for two of the departments involved in Mr Jones’ care, one has not been carried out by the Emergency Department, despite concerns raised at inquest by the witness from that team. I am concerned that potential learning, which may make a difference to future patients presenting with atypical aortic dissections, has not been identified or passed on to clinicians within the emergency department and any other relevant departments.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Potential ineffectiveness of training on atypical aortic dissections
Wider context from the report “2. Despite Mr Jones’ clinical picture changing whilst in the emergency department, the middle grade doctor reviewing Mr Jones did not alert a senior doctor of the change. I am concerned that training in relation to atypical aortic dissections brought to my attention in evidence at this and a previous inquest, and to my coroner colleague’s attention in inquests they conducted, may not have been ineffective. I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority, and a risk of death from undiagnosed aortic dissections may follow.
” 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 Collaborate with the East Midlands Aortic Network to incorporate regional best practice and learning into Acute Aortic Dissection diagnosis improvement.
Verbatim wording from the response “The Acute Aortic Dissection Diagnosis improvement work is in liaison with colleagues from across the East Midlands Aortic Network to ensure inclusion of best practice and learning from other regional centres across the network and National Programmes.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
10 Jul 2025 Mrs Gemma Louise Poterajko · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of a written lead extraction standard operating procedure recording planning discussions and realistic cardiac surgical involvement View source Lack of clarity about timely attendance by the full cardiac surgical team at lead extraction procedures View source Lack of formalised documented risk stratification and resource planning for lead extraction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Gemma Louise Poterajko · 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 Gemma Louise Poterajko died on 22 August 2024 at City Hospital in Nottingham following a pacemaker lead extraction procedure. She suffered catastrophic bleeding from tears in the left subclavian and left innominate veins and subsequently developed multi-organ failure. The concerns identified were the lack of formal risk stratification, a written Trust standard operating procedure, and clarity about timely cardiac surgical support for lead extraction 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written lead extraction standard operating procedure recording planning discussions and realistic cardiac surgical involvement
Wider context from the report “1. The lack of a formalised documented system of risk stratification for Lead extraction. The consequence is that there is a lack of clear planning for what may be needed from the cardiac surgical team, in terms of urgent surgical expertise, theatre staff support and perfusion team support, for any given lead extraction
2. The lack of a written Trust Standard Operating Procedure for Lead extraction that includes a record of the planning discussion, and sets out realistic cardiac surgical involvement when this is necessary
3. The lack of clarity as to how the full cardiac surgical team can within their resources currently, or planned for, provide necessary attendance in a timely way at a given Lead extraction procedure, as per international expert consensus
I am not reassured that necessary actions to address these serious issues identified are in place.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about timely attendance by the full cardiac surgical team at lead extraction procedures
Wider context from the report “1. The lack of a formalised documented system of risk stratification for Lead extraction. The consequence is that there is a lack of clear planning for what may be needed from the cardiac surgical team, in terms of urgent surgical expertise, theatre staff support and perfusion team support, for any given lead extraction
2. The lack of a written Trust Standard Operating Procedure for Lead extraction that includes a record of the planning discussion, and sets out realistic cardiac surgical involvement when this is necessary
3. The lack of clarity as to how the full cardiac surgical team can within their resources currently, or planned for, provide necessary attendance in a timely way at a given Lead extraction procedure, as per international expert consensus
I am not reassured that necessary actions to address these serious issues identified are in place.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formalised documented risk stratification and resource planning for lead extraction
Wider context from the report “1. The lack of a formalised documented system of risk stratification for Lead extraction . The consequence is that there is a lack of clear planning for what may be needed from the cardiac surgical team, in terms of urgent surgical expertise, theatre staff support and perfusion team support, for any given lead extraction
2. The lack of a written Trust Standard Operating Procedure for Lead extraction that includes a record of the planning discussion, and sets out realistic cardiac surgical involvement when this is necessary
3. The lack of clarity as to how the full cardiac surgical team can within their resources currently, or planned for, provide necessary attendance in a timely way at a given Lead extraction procedure, as per international expert consensus
I am not reassured that necessary actions to address these serious issues identified are in place.
” 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 Publish and implement a Trust-wide lead-extraction SOP requiring dedicated MDT review, documented planning, and escalation to joint cardiology–cardiac surgery MDT review for complex cases.
Verbatim wording from the response “2. Lack of a written Trust SOP including planning discussions and cardiac surgical involvement” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a documented Green/Amber/Red risk-stratification system using validated tools and clinical judgment to define required surgical, theatre and perfusion support.
Verbatim wording from the response “Following the recent Inquest regarding the sad death of Mrs Gemma Louise Poterajko as a result of a transvenous lead extraction (TLE), we acknowledge your concerns and have now developed and implemented a formal Standard Operating Procedure (SOP) for TLE at the Trent Cardiac Centre, Nottingham University Hospitals NHS Trust. This SOP has been drawn from the British Heart Rhythm Society (BHRS) Standards for Lead Extraction (2018).” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish risk-based cardiac surgical involvement requirements, including on-call cover, advance coordination, team presence and emergency equipment readiness for higher-risk procedures.
Verbatim wording from the response “The SOP specifies the level of cardiac surgical involvement:” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
24 Nov 2023 Michael David Daft · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Lack of effective communication between Multi-Disciplinary Teams from different specialisms for patients on more than one treatment pathway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael David Daft · 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
Michael David Daft was diagnosed with rectal cancer and a left renal mass, later confirmed as renal cell carcinoma. He died at City Hospital, Nottingham, on 10 November 2022 from a perforated bowel secondary to tumour progression; the report raised concerns about ineffective communication between multidisciplinary teams when patients are on more than one treatment pathway.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between Multi-Disciplinary Teams from different specialisms for patients on more than one treatment pathway
Wider context from the report “There is little evidence to date of effective communication between Multi-Disciplinary Teams (MDT) from different specialisms when a patient is on more than one treatment pathway.
” 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 Operate a monthly MDT Excellence meeting with representation from each clinical division.
Verbatim wording from the response “• In addition to all the above work we also have a regular MDT excellence meeting on a monthly basis as briefly mentioned. This meeting has one or more representatives present form each clinical division that feed their expertise in to the process of the MDT to help standardise the process across board.” Source location Response from Nottingham University Hospitals 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 Write overarching and individual MDT standard operating procedures to standardise MDT processes.
Verbatim wording from the response “• Agreed Standard Operating Procedures (SOPs) for individual MDT’s to be written with overarching MDT SOP to standardise the MDT process: Work is currently taking place on writing the overarching MDT SOP in conjunction with the Cancer Centre management team, Lead Cancer Clinician and other members of the MDT excellence project group. The overarching MDT SOP deadline is March 2024 and a plan is to complete 2-3 individual MDT SOPs a month. We have already started work on the individual SOPs and already completed 2-3 last month.” Source location Response from Nottingham University Hospitals 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 Develop and deliver standardised induction and refresher training for MDT coordinators.
Verbatim wording from the response “• Training and sharing: As documents and IT work are completed the Cancer Centre are supporting training and will be working on an agreed in house training programme for new starters and also to provide refresher training to in house MDT coordinators that again can be shared with Divisions to help” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute a Trust-wide safety briefing on risks affecting patients on multiple specialty pathways.
Verbatim wording from the response “Safety Snippet
- The Safety Team have composed a ‘safety snippet’ (a succinct safety briefing) distributed across the Trust to remind colleagues of the potential risks to patients on multiple speciality pathways, particularly when waiting times for investigations are prolonged. The importance of communicating the need for prioritisation of investigation with reference to clinical concern and potential impact of deterioration of the presenting condition has been highlighted.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement direct Pathology Medway referrals for Cancer MDTs.
Verbatim wording from the response “• Cancer MDTs which receive referrals directly from Pathology department to have Pathology Medway referral in place by August 2024: We have a minimum of 34 MDTs that need to be able to refer via the NUH digital system direct from pathology. We have 8 sites built and 6 in use as of January 2024. The role out of these referrals subsequently will be implemented quickly as is a standardised form.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Careflow referral capability for all Cancer MDTs.
Verbatim wording from the response “• All Cancer MDTs at NUH will have MDT referral in place on Careflow by August 2024: We have a minimum of 34 MDTs that need to be able to refer via the NUH digital system. We have 19 sites that are already live and up and running, 5 sites that are in consultation / building phase and 7 areas that requiring scoping. These 7 sites are at the end of the schedule due to them having an involvement with tertiary centres or are a regional MDT so require more planning.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree and pilot a standardised cross-Trust MDT referral process.
Verbatim wording from the response “• Agree and pilot a standardised process for MDT referrals between Trusts by October 2024: We have already completed an initial scope and started discussions around tertiary referrals and are in the process of writing a business case for a digital system ‘Refer a patient’ for external referrals for MDT to NUH. This is fully auditable, contains a timeline of patient activity and minutes can be sent direct back to referred in a timely manner. Once a patient has been referred via this system, any activity that happens the referrer will receive either an SMS alert or email that an activity has taken place including when minutes and actions can be assigned following MDT.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Streamline internal and external MDT outcome distribution, including development of web-based Infoflex recording and verification.
Verbatim wording from the response “• MDT outcomes and distribution process: Work has already started at looking at how MDT outcomes are distributed and work will take place in line with Information Governance procedures and the MDT excellence project to streamline this process both internal and external. This is of particular relevance in this case. Currently the internal process within the Cancer Centre, is to send all outcomes to the agreed core member distribution list. If a referrer is outside of the agreed core membership they will only receive the information on the patient they have referred with via NUH email or NHS.net if external. The outcomes are also uploaded for NUH patients within NotIS, once verified, within 48 hours.” Source location Response from Nottingham University Hospitals NHS Trust
Open published response
6 Jul 2023 Gordon Harry Renfrew · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to maintain effective communication and working relationships between stroke and neurosurgical teams View source Lack of clear Stroke team understanding of NICE guidance on decompression craniectomy View source Limited opportunities for joint case discussion and learning between Stroke and Neurosurgical teams View source Failure to finalise the Standard Operating Procedure for decompression craniectomy monitoring and referral criteria View source See 1 more concern
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. 5
Action
Implement agreed cross-specialty admission, procedure, post-procedure care and referral responsibilities, with electronic notification of relevant teams.
Stated completedThe respondent said that this action was complete when they made their response on 7 July 2023. View source
Action
Discuss cross-specialty cases at service morbidity and mortality meetings, share minutes and actions, and involve relevant specialties.
Stated plannedThe respondent said that this action was planned when they made their response on 7 July 2023. View source
Action
Develop joint learning strategies for Stroke, Neurosurgery and Neuro-Radiology teams.
Stated plannedThe respondent said that this action was planned when they made their response on 7 July 2023. View source
Action
Finalise and circulate a cross-department SOP incorporating NICE guidance, monitoring requirements and referral criteria for decompressive hemicraniectomy.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023. View source
Action
Deliver decompressive surgery education through multidisciplinary teaching, induction training, nursing sessions, registrar teaching and simulation.
Stated completedThe respondent said that this action was complete when they made their response on 7 July 2023. View source See 2 more actions
×
AI-generated summary
Gordon Harry Renfrew · 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
Gordon Harry Renfrew died at Queens Medical Centre on 14 June 2022 after a severe and extensive stroke caused by a large cerebral infarction. The report identified concerns about limited communication and working relationships between the stroke and neurosurgical teams, limited understanding of NICE guidance on decompression craniectomy, and insufficient opportunities for joint case discussion and learning. It stated that the NICE guidance was not followed and that discussions with the family about the timing of decompression craniectomy should have occurred earlier.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective communication and working relationships between stroke and neurosurgical teams
Wider context from the report “• There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear Stroke team understanding of NICE guidance on decompression craniectomy
Wider context from the report “• There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery . The planned Standard Operating Procedure, which may set out this clarity is not yet finalised.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited opportunities for joint case discussion and learning between Stroke and Neurosurgical teams
Wider context from the report “• There are currently limited opportunities for joint case discussion and learning between the Stroke and Neurosurgical teams . The Interventional Neuroradiologists could of course also usefully participate in such Educational opportunities - I note it was ████████, (Consultant in Interventional Neuroradiology) rather than the Stroke team, who asked that Gordon was reviewed by the Neurosurgical team on the early evening of the 7th June 2022
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the Standard Operating Procedure for decompression craniectomy monitoring and referral criteria
Wider context from the report “• There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement agreed cross-specialty admission, procedure, post-procedure care and referral responsibilities, with electronic notification of relevant teams.
Verbatim wording from the response “The Trust held a Joint PFD response meeting 7.8.23 chaired by ████████” Source location Response from Nottingham University Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss cross-specialty cases at service morbidity and mortality meetings, share minutes and actions, and involve relevant specialties.
Verbatim wording from the response “Cases involving both specialities will continue to be discussed at service M & M meetings and relevant colleagues from other specialities involved in the delivery of care will be invited to the meeting. Cross speciality attendance may not always be feasible but regardless, the minutes of individual speciality meetings are to be shared across specialties and actions should be discussed with governance and service leads. This is to be implemented across the Trust.” Source location Response from Nottingham University Hospital
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 Develop joint learning strategies for Stroke, Neurosurgery and Neuro-Radiology teams.
Verbatim wording from the response “There are currently limited opportunities for joint discussion and learning between the Stroke and Neurosurgical teams. The Interventional Neuro-radiologists could of course also usefully participate in such Educational activities.” Source location Response from Nottingham University Hospital
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 Finalise and circulate a cross-department SOP incorporating NICE guidance, monitoring requirements and referral criteria for decompressive hemicraniectomy.
Verbatim wording from the response “There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure which may set out this clarity is not yet finalised.” Source location Response from Nottingham University Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver decompressive surgery education through multidisciplinary teaching, induction training, nursing sessions, registrar teaching and simulation.
Verbatim wording from the response “The Stroke Department also held a teaching session on Decompressive Hemicraniectomy for ischaemic stroke on 3.7.2023.” Source location Response from Nottingham University Hospital
Open published response
17 Oct 2022 Carl Wright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of easy access to input from more experienced doctors View source Inexperienced junior doctors providing the majority of medical care and assessing deteriorating patients View source Failure to review most blood test results in a timely manner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carl Wright · 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
Carl Wright underwent complex cardiac surgery and was later transferred to a rehabilitation unit that was not suited to his condition. An infection and abdominal abscess were not identified promptly, with concerns including reliance on inexperienced junior doctors without easy access to senior input and delays in reviewing blood test results. He developed sepsis and died on 29 October 2021.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of easy access to input from more experienced doctors
Wider context from the report “(1) The majority of medical care, including the identification and assessment of deteriorating patients, was done by inexperienced junior doctors with no easy access to input from more experienced doctors ;
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inexperienced junior doctors providing the majority of medical care and assessing deteriorating patients
Wider context from the report “(1) The majority of medical care, including the identification and assessment of deteriorating patients, was done by inexperienced junior doctors with no easy access to input from more experienced doctors;
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review most blood test results in a timely manner
Wider context from the report “(2) There was an established culture and practice of most blood tests results not being reviewed in a timely manner .
” 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 Develop induction guidelines and an escalation process for junior doctors managing patients at risk of deterioration in Linden Lodge.
Verbatim wording from the response “All patients who are planned to be transferred from an NUH in patient bed into Linden Lodge are now required to be physically assessed and reviewed by a Consultant from Linden Lodge, prior to transfer. This is to ensure that the patient is medically stable and suitable for transfer and for care within the Neuro-Rehabilitation Unit. The team are developing induction guidelines for junior doctors working in Linden Lodge, supported by an escalation process where a patient may be at risk of clinical deterioration [completion date 31/12/2022].” Source location Response from Nottingham University Hospital 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 a specialty referral and escalation procedure for City Campus patients based on their presenting condition.
Verbatim wording from the response “A Standard Operating Procedure [SOP] has previously been developed which outlines which medical speciality should be referred/escalated to at the City campus based on the presenting condition. For example, if postoperatively a City-based patient has signs of post-operative pneumonia the guidance means the responsible surgical team contacts the Specialty Registrar [SPR] for advice which in this scenario would be from the respiratory team, with the patient remaining under the care of the surgical team unless the respiratory team formally transfer the patient under their care. There are a small group of patients who do not clearly “fit” into this process, for example, presentations such as sepsis of unknown origin.” Source location Response from Nottingham University Hospital 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 Require consultant assessment and review before transferring inpatients to Linden Lodge.
Verbatim wording from the response “All patients who are planned to be transferred from an NUH in patient bed into Linden Lodge are now required to be physically assessed and reviewed by a Consultant from Linden Lodge, prior to transfer. This is to ensure that the patient is medically stable and suitable for transfer and for care within the Neuro-Rehabilitation Unit. The team are developing induction guidelines for junior doctors working in Linden Lodge, supported by an escalation process where a patient may be at risk of clinical deterioration [completion date 31/12/2022].” Source location Response from Nottingham University Hospital 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 daily review and documentation of requested blood tests, incorporating the process into ward rounds with contingencies for delays.
Verbatim wording from the response “A SOP has been developed such that the review of all requested tests for patients are reviewed on a daily basis, supported by good documentation practice in the medical notes. This process has been built into the weekly ward round. Contingencies are in place if the weekly ward round is delayed or does not go ahead.” Source location Response from Nottingham University Hospital Foundation Trust
Open published response
23 Dec 2021 William DOLEMAN and 3 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Lack of accountability between professionals for robust procedure vetting View source Failure to record the information considered during procedure vetting View source Lack of accountability between professionals for consent View source Failure to personalise consent View source Failure to identify all patient factors relevant to the clinical indication for and safety of ERCP before the procedure View source Failure to discuss relevant ERCP patient factors with the patient View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William DOLEMAN and 3 others · 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
Four patients died following ERCP-related complications within a six-month period. The concerns included inadequate pre-procedure assessment and patient pathways, insufficient recording of procedure vetting, non-personalised consent, and unclear accountability between professionals for vetting and consent.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accountability between professionals for robust procedure vetting
Wider context from the report “4. A lack of accountability between professionals for ensuring robust vetting and consent.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the information considered during procedure vetting
Wider context from the report “2. A lack of robust system for the recording of vetting of the procedure , capturing what information has been considered as part of this process .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accountability between professionals for consent
Wider context from the report “4. A lack of accountability between professionals for ensuring robust vetting and consent .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to personalise consent
Wider context from the report “3. Consent is not personalised , contrary to recommendations made by the ESGE in December 2019.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify all patient factors relevant to the clinical indication for and safety of ERCP before the procedure
Wider context from the report “1. A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss relevant ERCP patient factors with the patient
Wider context from the report “1. A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient .
” 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 the redesigned Medway-based ERCP referral pathway with expanded clinical-risk and consent information fields.
Verbatim wording from the response “The following actions have been taken to address this concern:” Source location 2021-0432-Response-from-City-Hospital-Campus_Published
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 Amend patient information and consent forms to document operator experience or supervision arrangements and enhanced individual risk.
Verbatim wording from the response “• Patient information and consent forms will be amended to include a statement that “I understand that you cannot give me a guarantee that particular person will perform the procedure. The person performing the procedure will have appropriate experience or expert supervision”.” Source location 2021-0432-Response-from-City-Hospital-Campus_Published
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 Record ERCP referral-vetting outcomes and considered information as visible Medway clinical notes.
Verbatim wording from the response “• The Medway referrals will be vetted daily by consultants who undertake ERCPs in dedicated job planned time.” Source location 2021-0432-Response-from-City-Hospital-Campus_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide inpatient information booklets and obtain consent through ERCP endoscopist ward reviews before procedures.
Verbatim wording from the response “It is not currently possible for individual personalised risk to be calculated precisely although there are aspirations for this at some point in the future. It is possible to provide estimates of the relative risk to an individual patient in relation to the population risks and to ensure that this is documented in the patient record. A number of actions to support this have already commenced:” Source location 2021-0432-Response-from-City-Hospital-Campus_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate two permanent consultant-staffed clinics to discuss ERCP indications, risks and alternatives with referred outpatients.
Verbatim wording from the response “• Two new 2-hour clinics have been set up, that will run 52 weeks a year, staffed by consultants who undertake ERCPs. These sessions have already commenced and permanent funding is currently being agreed. This clinic time will be used to meet, either virtually or in person, with all out-patients referred for ERCP to discuss the indications, risks and alternatives.” Source location 2021-0432-Response-from-City-Hospital-Campus_Published
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 Precise individualised risk cannot currently be calculated, limiting the ability to personalise ERCP consent precisely.
Verbatim wording from the response “3. Consent is not personalised, contrary to recommendations made by the ESGE in December 2019.” Source location 2021-0432-Response-from-City-Hospital-Campus_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 The described vetting and consent arrangements are expected to resolve accountability between professionals, so no additional action is identified.
Verbatim wording from the response “4. A lack of accountability between professionals for ensuring robust vetting and consent.” Source location 2021-0432-Response-from-City-Hospital-Campus_Published
Open published response
21 Oct 2021 Quinn Lias Parker · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Failure to make careful, considered placenta-interference or disposal decisions with early coroner discussion View source Failure to retain the placenta for full paediatric post mortem examination before coronial reporting 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
Quinn Lias Parker · 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
Quinn Lias Parker was born in very poor condition and died two days later, after remaining extremely unwell from shortly after birth. The placenta was cut into or dissected after his death without discussion with the Coroner, limiting the paediatric post-mortem examination and the investigation into the circumstances and likely cause of death. The report also identifies repeated cases in which placental examination was compromised following early neonatal deaths in Nottingham.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make careful, considered placenta-interference or disposal decisions with early coroner discussion
Wider context from the report “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death.
In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case.
2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning.
3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain the placenta for full paediatric post mortem examination before coronial reporting
Wider context from the report “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death.
In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case.
2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner . This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning.
3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.
” 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 Discuss placenta examination with the Coroner’s office when a neonatal death occurs within the 96-hour Pathology stop period.
Verbatim wording from the response “This along with the longer ‘stop’ period of 4 days will, we hope, ensure that for the majority of relevant deaths in the neo-natal period there will be an opportunity for your office to have further communication with Pathology regarding the examination of the placenta.” Source location Response from NUH (3)
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 Maintain a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.
Verbatim wording from the response “Last year, in the light of your PFD report, an immediate 48 hour stop was put on the dissection of all placentas. However we have since reviewed the proposed processes and the length of that stop has been extended and is now set at 96 hours (ie 4 days) for all placentas that are sent to Pathology. A placenta may be fixed during that period, to prevent its deterioration, but it will not be dissected.” Source location Response from NUH (3)
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether placental examination processes need adaptation after receiving further information about the examination.
Verbatim wording from the response “In response to this Report the Trust will develop a standard procedure such that in the case of any neonatal death within 48 hours of birth the medical examiner team will inform the pathology laboratory of this at the very earliest opportunity. Once further information is gained in relation to the placental examination the Pathology Department will review whether there needs to be any adaptation to current examination processes.” Source location Response from NUH
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 Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.
Verbatim wording from the response “After consultation with Obstetricians, Neonatologists, Pathologists and Digital Lead, it is the view of the Trust that it is not proportionate nor practically achievable to devise a process that would reliably allow for this given that all of the 975 admissions to NICU each year are, by the very nature of NICU, neonates who are very unwell and may go on to die. The death of a neonate on NICU is not predictable in a way that could reliably allow us to identify the 25 or so neonates who do actually die each year. This is why we have determined that extending the Pathology stop period across the board for all placentas, and having discussions with your office where a death occurs within 96 hours, is a preferable and more realistically achievable approach.” Source location Response from NUH (3)
Open published response
21 May 2021 Morris REDDINGTON · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to review the electronic Patient Report Form during emergency department handover View source Failure to resolve electronic Patient Report Form access problems View source Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke 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
Morris REDDINGTON · 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
Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review the electronic Patient Report Form during emergency department handover
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form . The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone .
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution.
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre.
Whilst ever this problem persists without resolution, there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve electronic Patient Report Form access problems
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form. The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone.
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution .
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre .
Whilst ever this problem persists without resolution , there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke
Wider context from the report “In January 2018, NHS England published its Clinical Commissioning Policy on the use of Mechanical Thrombectomy as treatment for acute ischaemic stroke (all ages).
The aim of the Policy reports to be two-fold; to improve outcomes for adults with stroke, and to improve access to mechanical thrombectomy as soon as possible after the onset of stroke symptoms.
Despite the publication of the policy some 3 years ago, there remains very limited access to 24/7 mechanical thrombectomy . Save for two Trusts in London, and the West Midlands Network, I am not aware of others providing a 24/7 service. There certainly is no such service in the East Midlands .
There is clear geographical disparity in the access to this vital, life-saving service .
Mechanical thrombectomy would likely have avoided Mr Reddington’s death. Instead, because Mr Reddington was unfortunate enough to suffer a stroke outside of the service’s operational hours (Monday to Friday 8am to 4pm), his family were left to watch his deterioration, knowing that a treatment had the potential to save his life, but that such treatment simply was not offered after 4pm .
This is a situation that no family ought to be placed in.
” Open source report
9 Oct 2020 WYNTER SOPHIA ANDREWS · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to provide sufficient midwifery care capacity for multiple families View source Failure to base critical care-allocation decisions on individualised patient risk View source Failure to listen and respond to staff safety concerns View source Failure to promote and facilitate professional challenge View source Lack of robust initial critical analysis of deaths View source See 2 more concerns
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. 20
Action
Classify unexpected early-term neonatal deaths and intrapartum term stillbirths as Serious Incidents, subject to stated exclusions.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2020. View source
Action
Pilot an obstetric handover checklist incorporating staff-break information to support safe-staffing assessment.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Operate twice-daily senior leadership Safe Today visits and safety briefings assessing staffing, acuity, care and escalation needs across both maternity sites.
Status unclearThe respondent did not make the status of this action clear when they made their response on 1 December 2020. View source
Action
Contact bereaved families through the Medical Examiner Service and update bereavement booklets with relevant contact details.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Recruit additional midwives and continue recruitment, using agency staff and overtime temporarily to address the identified staffing shortfall.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Pilot live Perinatal Mortality Review Tool information to inform maternity case review discussions before all inputs are available.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Review and strengthen maternity multidisciplinary case review meetings by promoting inclusivity, midwives’ voices and parents’ views.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Update the Maternity Communication guideline to incorporate CTG, SBAR, escalation and professional-challenge concepts.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Revise the Child Death Review and Medical Examiner referral form to identify all professionals involved in antenatal and postnatal care.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Implement the obstetric shift handover checklist with multidisciplinary attendance and structured review of women across maternity areas.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2020. View source
Action
Purchase Perinatal Institute intrapartum notes containing prompts for maternal preferences and procedure-risk documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Establish early multidisciplinary review meetings within five working days of child deaths to gather clinical information and parents’ views.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Pilot CTG interpretation training covering SBAR handover, escalation and professional challenge, with competency assessment and planned online rollout.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Review maternity Datix incidents weekly for themes and actions, and provide learning feedback to staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Build and use a digital application consolidating data sources to identify potential high-risk cases for Serious Incident investigation.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2020. View source
Action
Hold communication events enabling staff to meet leadership and raise professional challenges.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020. View source
Action
Deliver training and awareness seminars for maternity and paediatric staff on Medical Examiner information requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Embed CTG, SBAR, escalation and professional-challenge concepts into multiprofessional emergency training and in-situ skills drills.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2020. View source
Action
Implement and educate staff on the updated intrapartum risk assessment document for every latent or established labour presentation.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2020. View source
Action
Update incident escalation reports with broader contextual review prompts, care-quality ratings and Serious Incident definitions.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2020. View source See 17 more actions
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AI-generated summary
WYNTER SOPHIA ANDREWS · 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
Wynter Sophia Andrews died after being delivered by caesarean section on 15 September 2019, following missed opportunities to monitor her wellbeing and concerns that she should have been delivered earlier. The report identified concerns about the lack of robust initial critical analysis of deaths and an unsafe culture within Midwifery Services, including failures to respond to staff safety concerns, facilitate professional challenge, and make decisions based on individualised patient 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient midwifery care capacity for multiple families
Wider context from the report “(a) Failure to listen to and respond to staff safety concerns
I have made findings that the Maternity Services were operated in an unsafe manner on 14 – 15 September 2019. Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require . Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence. I saw evidence that staff were repeatedly raising their concerns through the Datix system, but they told me they would receive no feedback in reply nor would anything change.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to base critical care-allocation decisions on individualised patient risk
Wider context from the report “(c) Failure to reach decisions based on individualised patient risk
It was custom and practice that critical decisions, such as which patient to transfer to the labour suite when demand outstripped supply, were made in isolation without reading the patient notes, speaking with the midwife caring for the patient, without seeing the patient, without seeking medical input and, crucially, without assessing individualised patient risk at the point the patient was unable to receive the care on the labour ward that they required.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to listen and respond to staff safety concerns
Wider context from the report “(a) Failure to listen to and respond to staff safety concerns
I have made findings that the Maternity Services were operated in an unsafe manner on 14 – 15 September 2019. Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require. Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence . I saw evidence that staff were repeatedly raising their concerns through the Datix system, but they told me they would receive no feedback in reply nor would anything change .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promote and facilitate professional challenge
Wider context from the report “(b) Failure to promote and facilitate professional challenge
Midwives spoke of their inability to professionally challenge plans made by medical staff , even in circumstances where they felt the plan might harm mother or baby. The culture failed to promote professional challenge and multi-disciplinary care of women. Decisions were often made in isolation, without understanding the full background and patient wishes.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust initial critical analysis of deaths
Wider context from the report “1. Lack of robust initial critical analysis of deaths
Prior to 1 October 2019, when the Notification of Deaths Regulations 2019 came into force, the Trust were mandated by local agreement to refer every child death (even expected deaths) to HM Coroner.
However, the implementation of the Regulations, removed the discretion of coroners to set local referral criteria. Wynter’s death occurred just two weeks prior to the implementation of the Regulations, and was therefore referred to HM Coroner as ‘standard procedure’.
The referral itself expressed that Wynter’s death was ‘Expected’ and as a result, there had been no review performed by the Rapid Response Clinician for Unexpected Paediatric Deaths.
The checklist on the reverse of the referral to HM Coroner indicated that the only trigger for referral was the “Deceased’s Age”. The boxes for neglect, unnatural death, allegations of negligence, and death associated with a clinical incident were all left unticked.
The detail within the body of the report made no reference to any of the failings that have become apparent throughout the inquest, and indeed, would have been apparent upon robust scrutiny of the CTG trace and medical records available at the time.
The referral explained that the reporting doctor was happy to propose a cause of death, and happy to complete the Medical Certificate of Cause of Death. The effect of this, would have meant Wynter’s death being registered as a natural death and without investigation by the Coroner.
As is usual practice, before the Coroner reaches a decision, the Coroner’s officer makes contact with the family to see if they have any concerns. Understandably, this is a shocking and upsetting time for the family, but they had the clarity of thought at that stage to express some concerns about the events leading up to labour, which were sufficient for the Coroner to direct an independent post mortem examination.
The full picture then unfolded through the coronial investigation and the separate Health Sector Investigation Branch inquiry.
I am concerned that the lack of robust initial critical analysis of deaths has the potential to lead to missed opportunities to learn lessons that are vital to improving patient safety . Mrs ████████ agreed that one of the recommendations to come out of this inquest is a review of the current 72-hour table top review of care. This risk goes beyond obstetric deaths and has the ability to prevent learning from deaths within other Divisions of the Trust.
For that reason, I am informing the Trust’s Chief Executive of my concerns through a PFD report.
” 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 Classify unexpected early-term neonatal deaths and intrapartum term stillbirths as Serious Incidents, subject to stated exclusions.
Verbatim wording from the response “The national Serious Incident Framework (2015) does not provide an explicit list of triggers/categories that would indicate a case should be declared and investigated as a Serious Incident (SI). In response to the national focus on reducing stillbirths and following the delay to declaring the WA case a Serious Incident, the Trust has decided to declare unexpected early [term] neonatal deaths [HSIB define this as days 0-6] and intrapartum term stillbirths as Serious Incidents. This process will exclude babies on an identified care pathway with life-limiting conditions including congenital abnormalities, except where there has been a deviation from the pathway that requires further investigation.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot an obstetric handover checklist incorporating staff-break information to support safe-staffing assessment.
Verbatim wording from the response “• A medical obstetric handover checklist is being piloted and will include a question for the outgoing medical team regarding whether they have been able to take breaks. This will be used, along with the midwifery acuity, to assess the safe staffing of the unit for the preceding 12 hour period.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate twice-daily senior leadership Safe Today visits and safety briefings assessing staffing, acuity, care and escalation needs across both maternity sites.
Verbatim wording from the response “Safe Today Process:” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact bereaved families through the Medical Examiner Service and update bereavement booklets with relevant contact details.
Verbatim wording from the response “Having considered the matters of concern in the Preventing Future Deaths report it is now determined that the processes in support of early review/scrutiny by the Medical Examiners can be further strengthened through a number of planned improvements, outlined below. Unless otherwise stated all actions will be complete by 1st February 2021:” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit additional midwives and continue recruitment, using agency staff and overtime temporarily to address the identified staffing shortfall.
Verbatim wording from the response “• In December 2019, a Birthrate Plus (BR+) staffing review on maternity services was undertaken. The NUH report by the national body undertaking this work was published in June 2020. This highlighted that, when considering the acuity of care required in the maternity services, there was a shortfall in the midwifery staffing establishment of 73 Whole Time Equivalent (WTE). We have been recruiting to resolve this issue and fifteen newly qualified midwives commenced in September, 23.84 WTE new starters were recruited in late October (26 individuals) and will start in January 2021. A further recruitment campaign is underway. Agency staff and overtime have been offered to bridge the gap in the interim. Staffing levels and acuity are being monitored daily, and activity diverted or reduced, or staff redeployed, as necessary to maintain safe staffing levels.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot live Perinatal Mortality Review Tool information to inform maternity case review discussions before all inputs are available.
Verbatim wording from the response “In addition, in support of the Multidisciplinary Team (MDT) Case Review Meeting in maternity, the Perinatal Mortality Review Tool (PMRT) will be used to inform the case review discussions. The PMRT is a national standardised tool designed to support high quality, systematic, multiprofessional reviews of stillbirths and neonatal deaths that take into account the views of the parents. The output of the reviews is the production of a report for parents that includes a plain English explanation of why their baby died and whether the care was appropriate. Full completion of the PMRT requires input from the parents, placental histology and post-mortem reports which can take several months to be returned. The use of a live version including all available information to date, to inform the case review meeting, is being piloted.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and strengthen maternity multidisciplinary case review meetings by promoting inclusivity, midwives’ voices and parents’ views.
Verbatim wording from the response “• The Multidisciplinary Team (MDT) Case Review Meeting in maternity (held every Monday) will be reviewed and strengthened by promoting inclusivity, the voice of the clinical midwives and the views of the parents. The review will form part of the Trust’s recently convened (November 2020) Maternity Transformation Governance Group.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Maternity Communication guideline to incorporate CTG, SBAR, escalation and professional-challenge concepts.
Verbatim wording from the response “• The NUH Maternity Communication guideline will be updated to include the above concepts, with a draft to be reviewed in January 2021.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Child Death Review and Medical Examiner referral form to identify all professionals involved in antenatal and postnatal care.
Verbatim wording from the response “Having considered the matters of concern in the Preventing Future Deaths report it is now determined that the processes in support of early review/scrutiny by the Medical Examiners can be further strengthened through a number of planned improvements, outlined below. Unless otherwise stated all actions will be complete by 1st February 2021:” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the obstetric shift handover checklist with multidisciplinary attendance and structured review of women across maternity areas.
Verbatim wording from the response “A checklist has been developed for the obstetric shift handover in conjunction with the patient safety and acute rescue team fellow at NUH. This includes attendance of the band 7 midwife and the anaesthetist as well as the obstetric team. The discussion involves an SBAR (structured) handover of all women on the main labour suite, Sanctuary (Alongside Midwifery-Led Unit) and an overview of triage and the inpatient wards. The handover checklist was launched on 16th November.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Purchase Perinatal Institute intrapartum notes containing prompts for maternal preferences and procedure-risk documentation.
Verbatim wording from the response “• NUH is purchasing the Perinatal Institute intrapartum notes. The notes include specific sections on maternal preferences and documentation of the risks and benefits of any proposed procedure or” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish early multidisciplinary review meetings within five working days of child deaths to gather clinical information and parents’ views.
Verbatim wording from the response “Having considered the matters of concern in the Preventing Future Deaths report it is now determined that the processes in support of early review/scrutiny by the Medical Examiners can be further strengthened through a number of planned improvements, outlined below. Unless otherwise stated all actions will be complete by 1st February 2021:” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot CTG interpretation training covering SBAR handover, escalation and professional challenge, with competency assessment and planned online rollout.
Verbatim wording from the response “• We have developed a training session for staff based around CTG interpretation, which includes the use of SBAR handover, and tools for escalation and professional challenge. This training package is currently being piloted with the intention of launching online training by mid December 2020. An associated competency assessment will test the application of these concepts.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review maternity Datix incidents weekly for themes and actions, and provide learning feedback to staff.
Verbatim wording from the response “• A weekly review of incidents reported on Datix is being undertaken by the maternity governance team. This includes a review of themes and actions. Feedback of learning to staff commenced on 1st November 2020.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Build and use a digital application consolidating data sources to identify potential high-risk cases for Serious Incident investigation.
Verbatim wording from the response “To further support the identification of cases (maternity or otherwise) which may meet the criteria for a Serious Incident Investigation, a digital application has been built that pulls data from multiple sources to help identify possible high risk cases. This would include, for example, where there may be a concurrent incident, complaint and claim. The application consolidates internal data in relation to patient deaths, formal complaints, family concerns, patient safety incidents, coroner’s inquests, clinical negligence claims and maternity early notifications.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold communication events enabling staff to meet leadership and raise professional challenges.
Verbatim wording from the response “• In December we have commenced a series of communication events allowing staff to meet directly with the leadership team, in which staff have been encouraged to raise professional challenge.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver training and awareness seminars for maternity and paediatric staff on Medical Examiner information requirements.
Verbatim wording from the response “Having considered the matters of concern in the Preventing Future Deaths report it is now determined that the processes in support of early review/scrutiny by the Medical Examiners can be further strengthened through a number of planned improvements, outlined below. Unless otherwise stated all actions will be complete by 1st February 2021:” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed CTG, SBAR, escalation and professional-challenge concepts into multiprofessional emergency training and in-situ skills drills.
Verbatim wording from the response “• We will embed these concepts into staff multi-professional emergency training and in situ skills drills.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and educate staff on the updated intrapartum risk assessment document for every latent or established labour presentation.
Verbatim wording from the response “The intrapartum risk assessment document has been updated and has been launched with accompanying staff education. The document is to be completed each time a woman presents in the latent phase or established labour. To evidence this, the maternity record keeping audit tool that is in development includes a question to assess compliance with this requirement.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update incident escalation reports with broader contextual review prompts, care-quality ratings and Serious Incident definitions.
Verbatim wording from the response “Revisions to the Trust incident escalation report (formerly referred to as the 72 hour report)” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
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 Serious Incident investigation excludes babies on identified life-limiting-condition pathways unless a deviation requires further investigation.
Verbatim wording from the response “The national Serious Incident Framework (2015) does not provide an explicit list of triggers/categories that would indicate a case should be declared and investigated as a Serious Incident (SI). In response to the national focus on reducing stillbirths and following the delay to declaring the WA case a Serious Incident, the Trust has decided to declare unexpected early [term] neonatal deaths [HSIB define this as days 0-6] and intrapartum term stillbirths as Serious Incidents. This process will exclude babies on an identified care pathway with life-limiting conditions including congenital abnormalities, except where there has been a deviation from the pathway that requires further investigation.” Source location 2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
Open published response
20 Feb 2019 Malcolm John Rathmell · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to establish how or why the anticoagulation chart was mislabelled View source Failure to maintain accurate patient identification on anticoagulation charts View source Failure to identify incorrect warfarin prescribing View source Failure to implement changes addressing the risk of incorrect prescribing View source Lack of ward-based pharmacy review View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Malcolm John Rathmell · 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
Malcolm Rathmell was admitted after a fall and his pelvic fracture was not diagnosed until several days later. He was incorrectly given warfarin intended for another patient, subsequently suffered retroperitoneal bleeding, and died after developing bronchopneumonia. Concerns included failures to identify the incorrect prescription, the absence of a ward-based pharmacy review, and insufficient implemented action to address the risk of future 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish how or why the anticoagulation chart was mislabelled
Wider context from the report “(3) It has not been possible to establish how or why this happened despite an extensive investigation by the Trust and a detailed enquiry during the inquest .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate patient identification on anticoagulation charts
Wider context from the report “(2) It has not been possible to identify when Patient B’s anti-coagulation chart was labeled with Mr Rathmell’s details , save that it is likely, on the balance of probabilities, that it took place on ward B3 between 1.30pm on 15.03.18 and 4.06am on 16.03.18.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify incorrect warfarin prescribing
Wider context from the report “(1) Mr Rathmell was treated and reviewed by a number of medical professionals from various disciplines between 14.03.18 and 22.03.18. No one identified during that time that he was being prescribed warfarin incorrectly.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement changes addressing the risk of incorrect prescribing
Wider context from the report “(5) The proposed actions being considered by the Trust to address the issue of incorrect prescribing are in their infancy and other than sharing the learning from the SI report, no other changes or action has been implemented to address the risk of 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward-based pharmacy review
Wider context from the report “(4) There was no ward based pharmacy review between 15.03.18 and 22.03.18.
” Open source report
19 Jan 2017 Teresa Dennett · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of a clear pathway for referral for life-saving neurosurgery View source Lack of input from stroke physicians in appropriate cases View source Deficiencies in diagnostic imaging View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Teresa Dennett · 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
Teresa Dennett suffered a rare type of stroke and was admitted to hospital on 6 February 2016. Attempts were made to arrange urgent neurosurgery, but transfer did not occur before she deteriorated and died later that morning. The principal concerns were the absence of a clear referral pathway for life-saving neurosurgery, inadequate access to diagnostic imaging, and insufficient input from stroke physicians in appropriate cases.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for referral for life-saving neurosurgery
Wider context from the report “I have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery ) and two further concerns (regarding diagnostic imaging, and input from stroke physicians into appropriate cases).
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of input from stroke physicians in appropriate cases
Wider context from the report “I have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery) and two further concerns (regarding diagnostic imaging, and input from stroke physicians into appropriate cases ).
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in diagnostic imaging
Wider context from the report “I have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery) and two further concerns (regarding diagnostic imaging , and input from stroke physicians into appropriate cases).
” 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 Continue monitoring the performance of the life-saving transfer protocol for adverse events.
Verbatim wording from the response “The significant national interest generated by this PFD have resulted in NUH adopting this policy of accepting patients for lifesaving intervention irrespective of critical care capacity from the time the PFD was issued. There have been no significant adverse events from this protocol to date but the performance will continue to be monitored.” Source location 2017-0026-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the stroke on-call consultant service to discuss atypical courses and acute complications, including potential urgent neurosurgical or neuroradiological intervention.
Verbatim wording from the response “Other concern 2 - Input from Stroke Consultants” Source location 2017-0026-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain formal ratification of the transfer protocol from the Mid Trent Critical Care Network and NUH.
Verbatim wording from the response “The next steps for this protocol are:” Source location 2017-0026-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the protocol and related expectations to regional hospitals, specialist organisations, local medical directors and all UK critical care units.
Verbatim wording from the response “Communications” Source location 2017-0026-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a protocol for accepting and transferring patients requiring life-saving specialist intervention irrespective of critical care capacity.
Verbatim wording from the response “The key concern of the Coroner was that “There should be a clear written protocol for patients requiring lifesaving surgery that allows immediate transfer of a patient to a place where an appropriate intervention can be undertaken.”” Source location 2017-0026-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate transfer may not be possible during major theatre infrastructure failure or when a major incident overwhelms theatre capacity.
Verbatim wording from the response “4. The only exceptions to the patient being accepted for immediate transfer as in 2 will be if there is major infrastructure failure in NUH theatres or a major incident that is overwhelming theatre capacity. In these exceptional circumstances the NUH consultant will discuss the patient with a consultant in an alternate specialist centre.” Source location 2017-0026-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
12 Oct 2016 Rohid SHERGILL · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Failure of information-sharing between trusts View source Unclear responsibility for ensuring parental competence in NGT feeding View source Lack of parental competence for first use of NGT feeding View source Repeated use of syringes for NGT aspirate pH testing View source Lack of staff training on information to record in shared care records View source Failure of clinicians visiting sick children at home to perform or confirm pH testing before medication administration View source Lack of clear allocation of a named keyworker or lead nurse for community care coordination View source See 4 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
Rohid SHERGILL · 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
Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of information-sharing between trusts
Wider context from the report “2. Information-sharing between the two trusts – by way of shared IT and / or the use of shared care folders kept in the family home – with clear training to staff on what information should be recorded there.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for ensuring parental competence in NGT feeding
Wider context from the report “1. Ensuring that parents of children fed in this way are completely happy with what they have to do, and understand the significance of it. There was clear confusion about whether this was the responsibility of the school nurse or the community nurses (then working separately). Urgent consideration should be given to an agreed protocol to ensure parental competence whenever an NGT is first used – in the community or in 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of parental competence for first use of NGT feeding
Wider context from the report “1. Ensuring that parents of children fed in this way are completely happy with what they have to do, and understand the significance of it. There was clear confusion about whether this was the responsibility of the school nurse or the community nurses (then working separately). Urgent consideration should be given to an agreed protocol to ensure parental competence whenever an NGT is first used – in the community or in 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Repeated use of syringes for NGT aspirate pH testing
Wider context from the report “5. There should be a review of the policy of syringes being used multiple times for pH testing aspirate from NGTs – and whether this results in a risk of contamination and therefore falsely reassuring results .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on information to record in shared care records
Wider context from the report “2. Information-sharing between the two trusts – by way of shared IT and / or the use of shared care folders kept in the family home – with clear training to staff on what information should be recorded there .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinicians visiting sick children at home to perform or confirm pH testing before medication administration
Wider context from the report “4. Training to physiotherapy teams regarding the importance of pH testing (or at least confirming this has been done) before administration of medication. This should be considered for other disciplines who routinely visit sick children at home and prescribe medication – such as occupational therapists / speech and language therapists.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear allocation of a named keyworker or lead nurse for community care coordination
Wider context from the report “3. Clear guidance on a named keyworker / lead nurse who is responsible for coordinating the care of children cared for in the community.
” Open source report
11 May 2015 Lydia Corah · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Failure to ensure that x-rays are performed for the patient for whom they are intended 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
Lydia Corah · 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
Lydia Corah died at the Trust hospital from multi-organ failure caused by Group A beta streptococcal sepsis. The report raised concerns about errors that led to her undergoing an X-ray intended for a different patient, causing delay in assessment and treatment and unnecessary radiation, and about the potential adverse effect on the intended patient.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that x-rays are performed for the patient for whom they are intended
Wider context from the report “1. That there was an error, or series of errors, which led to Mrs Corah undergoing an x ray which had been indicated for a different patient , so causing her to experience delay in assessment and treatment and to receive an unnecessary dose of radiation.
2. That the same error, or series of errors, would have adversely affected the patient for whom the x ray request had been properly intended .
” Open source report
23 Oct 2014 Phyllis Kerry · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to communicate relevant guidelines to relevant staff View source Absence of clear guidelines for managing patients with intra-cerebral bleeds while on Warfarin or similar medication View source Unclear responsibility for deciding when immediate reversal is needed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Phyllis Kerry · 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
Phyllis Kerry, who was taking long-term Warfarin, was admitted with symptoms suggestive of stroke and found to have a haemorrhagic stroke. She deteriorated and died after the intracerebral bleed increased. The principal concerns were uncertainty about which specialty was responsible for deciding on immediate Warfarin reversal, the absence of clear guidelines, and inadequate communication of relevant guidelines to staff.
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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant guidelines to relevant staff
Wider context from the report “(1) Which specialty takes responsibility for deciding when immediate reversal is needed?
(2) The absence of clear guidelines for dealing with patients presenting with intra-cerebral bleeds whilst on Warfarin or similar medication.
(3)The communication of relevant guidelines to relevant staff.
While none of the witnesses I heard from were aware of any relevant guidelines , it is possible that these may in fact already be in existence. Similarly, it may be that draft guidelines are being reviewed. However it was not clear from the evidence when / if these would be finalised.
If there are existing guidelines, it would concern me greatly that the witnesses I heard from were unaware of these , and I take the view that communication of guidelines is as important as the guidelines themselves .
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of clear guidelines for managing patients with intra-cerebral bleeds while on Warfarin or similar medication
Wider context from the report “(1) Which specialty takes responsibility for deciding when immediate reversal is needed?
(2) The absence of clear guidelines for dealing with patients presenting with intra-cerebral bleeds whilst on Warfarin or similar medication.
(3)The communication of relevant guidelines to relevant staff.
While none of the witnesses I heard from were aware of any relevant guidelines, it is possible that these may in fact already be in existence. Similarly, it may be that draft guidelines are being reviewed. However it was not clear from the evidence when / if these would be finalised.
If there are existing guidelines, it would concern me greatly that the witnesses I heard from were unaware of these, and I take the view that communication of guidelines is as important as the guidelines themselves.
” 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for deciding when immediate reversal is needed
Wider context from the report “(1) Which specialty takes responsibility for deciding when immediate reversal is needed?
(2) The absence of clear guidelines for dealing with patients presenting with intra-cerebral bleeds whilst on Warfarin or similar medication.
(3)The communication of relevant guidelines to relevant staff.
While none of the witnesses I heard from were aware of any relevant guidelines, it is possible that these may in fact already be in existence. Similarly, it may be that draft guidelines are being reviewed. However it was not clear from the evidence when / if these would be finalised.
If there are existing guidelines, it would concern me greatly that the witnesses I heard from were unaware of these, and I take the view that communication of guidelines is as important as the guidelines themselves.
” 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 Consider additional ways to make the guidance readily available, particularly inclusion in the NUH guideline app.
Verbatim wording from the response “I have also asked the NUH guideline group to consider other ways of making the guidance readily available, in particular this will be considered for inclusion within the NUH guideline APP which was widespread use within the NUH.” Source location 2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust2f
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 Communicate the new guideline to current trainee and consultant medical staff across emergency, stroke, neurosurgical and haematology services, with progress reviewed by the Medical Director’s office.
Verbatim wording from the response “I have asked the Heads of Service for the specialties involved (ED, Stroke Services, Neurosurgery, Haematology) to ensure that this new guideline is communicated to all current medical staff, both trainee and Consultant. This communication will be reviewed by the Medical Directors office to ensure that it is progressed appropriately. I have also asked for this issue to be included in medical staff specialty induction in order to ensure that new staff will also be made aware.” Source location 2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust2f
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 Agree a guideline for prompt treatment of warfarin patients presenting with intracranial haemorrhage.
Verbatim wording from the response “The new guideline to assist with the prompt and appropriate treatment of patients who are on warfarin presenting with Intra Cranial Haemorrhage has now been agreed by all parties involved and accompanies this letter.” Source location 2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust2f
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 Include the new guideline in medical staff specialty induction for incoming staff.
Verbatim wording from the response “I have asked the Heads of Service for the specialties involved (ED, Stroke Services, Neurosurgery, Haematology) to ensure that this new guideline is communicated to all current medical staff, both trainee and Consultant. This communication will be reviewed by the Medical Directors office to ensure that it is progressed appropriately. I have also asked for this issue to be included in medical staff specialty induction in order to ensure that new staff will also be made aware.” Source location 2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust2f
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 Share the agreed guideline with relevant medical staff and add it to the NUH guideline app.
Verbatim wording from the response “In addition to sharing with medical staff in the appropriate specialties we will also ask for this guideline to be added to the NUH guideline APP which will assist medical staff to access the guideline whenever required.” Source location 2014-0457-Response-by-Nottingham-University-Hospitals-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 Finalise a cross-specialty guideline clarifying anticoagulation reversal responsibility and enabling rapid intervention.
Verbatim wording from the response “A new guideline has been prepared which I am confident will provide more rapid intervention in the management of anticoagulation and will clarify which specialty is responsible for this element of care.” Source location 2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust
Open published response
24 Oct 2013 Mr Harold Elvidge · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Lack of consistent trust-wide safeguards against the mixing up of different types of fluids 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
Mr Harold Elvidge · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Harold Elvidge died on 2 November 2012 after the wrong fluid was used to keep an arterial line open, leading to misinterpreted blood sugar levels, drug administration and brain damage. The principal concern was that other parts of the trust might not have equally robust safeguards to prevent different types of fluids being mixed up, creating a risk of future 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 Nottingham University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent trust-wide safeguards against the mixing up of different types of fluids
Wider context from the report “(2) The evidence suggested that Omnicell cabinets may be available soon in E12 at the QMC. It was however clear that, although Critical Care at the City campus has Omnicell cabinets in place, this is not the case across the trust, nor even all critical care areas in the trust . While a mistake in the context of intensive care and arterial lines may be more serious for some patients, there could be equally catastrophic outcomes for patients in non critical care settings, if there remains a risk of different types of fluids being mixed up .
(3) Whilst mindful of the cost implications involved, I am concerned about the risk of future deaths occurring in other parts of the trust which may not have as robust a safety standard as Critical Care (certainly at the City Hospital campus) now appears to have.
(4) It is not for me to make specific recommendations regarding the purchase of specified equipment, but a trust-wide review of policies for safe storage of different types of fluids would reduce the risk of a similar tragedy occurring in future . This would include issues such as where these fluids are stored, how they are packaged and labelled, who is entitled to change bags, what checks are in place, and how this is recorded.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations