18 Mar 2026 Julie Anne Pytches · Prevention of Future Deaths report Essex
View report summary
Concerns raised 6 Failure to ensure consultants understand locally varying emergency policies and procedures View source Unclear roles and responsibilities for requesting ambulance attendance at major hospital events View source Insufficient staff understanding of emergency protocols View source Unavailability of relevant emergency protocols at the point of need View source Lack of plan for transfer to a tertiary centre View source Lack of process for doctors to notify private hospital management of practice limitations View source See 3 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. 13
Action
Clarify ambulance-activation responsibilities during theatre emergencies in local standard operating policies and emergency guides.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source
Action
Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026. View source
Action
Reinforce ambulance-activation pathways through simulation covering deterioration recognition, escalation, intervention, ambulance arrival and SBARD handover.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source
Action
Use policy-access and readership analytics to assure Consultant and staff engagement with critical emergency documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026. View source
Action
Update Consultant induction and practising-privileges renewal checklists to require notification of temporary or permanent practice limitations, including same-day changes.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source
Action
Update induction and practising-privileges renewal checklists to cover MyStaff access and locating local emergency policies.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source
Action
Operate MyStaff as a centralised platform for accessible Group and local policies, update alerts and critical-policy readership analytics.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Require explicit confirmation of workload, wellbeing and safe scope of practice in Consultant practising-privileges renewals.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Use SBARD as a decision-support tool for escalation and transfer discussions.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026. View source
Action
Roll out mandatory emergency-protocol induction for site leaders, night coordinators and senior nursing staff, including role responsibilities.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source
Action
Incorporate tertiary-referral criteria and senior clinician-to-ambulance communication into scenario-based training.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source
Action
Further develop the major-haemorrhage training module to clarify end-to-end processes and differences from NHS pathways.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2026. View source See 10 more actions
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AI-generated summary
Julie Anne Pytches · 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
Julie Anne Pytches died on 14 October 2023 during elective spinal surgery after suffering a covert probable arterial bleed, major haemorrhage and cardiac arrest while prone in the operating theatre. The report identifies concerns about emergency protocols, staff understanding and training, communication of clinicians’ practice limitations, and uncertainty about ambulance attendance and possible transfer to a tertiary centre.
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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consultants understand locally varying emergency policies and procedures
Wider context from the report “(2) Mrs Pytches suffered a major haemorrhage whilst undergoing spinal surgery and there was confusion about the protocol and procedures at the hospital . Consultants with practising privileges in this private healthcare organisation were not all aware of policies and emergency procedures required and these are subject to local variation within the Group organisation across the country . Doctors may have practising privileges in more than one hospital that may cause confusion as to what is required in individual hospitals within the Group. There is assurance that Consultants are required to acknowledge they have read policies, however this does not mean this local variation is clear particularly for a less frequently occurring emergency life-threatening event.
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Unclear roles and responsibilities for requesting ambulance attendance at major hospital events
Wider context from the report “(4) There was some confusion about the roles and responsibilities when there was a concern that an ambulance was required to attend to a major event to a private hospital where the patient was undergoing surgery in an operating theatre. Evidence was that Mrs Pytches was suffering from a major haemorrhage with an uncertain aetiology. There is a concern that Mrs Pytches did not regain stability such that she could have been safely moved and there was no plan as to whether Mrs Pytches required transfer to a tertiary centre. Calling an ambulance without an understanding of specifically what was required could impact on a future death taking this resource from a community emergency. Mrs Pytches already had the attendance of qualified surgeons and anaesthetists whilst suffering a major haemorrhage that could not be treated by community paramedics, however well qualified and experienced as in this case.
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff understanding of emergency protocols
Wider context from the report “(3) The site manager was new and although there had been some training for her role, there was a lack of understanding of the emergency protocols and this was also the case with nurses at the hospital for this event. A very senior member of the ambulance crew was attempting to assist the site co-ordinator as to locate the most relevant documents. Training needs to be embedded and protocols readily available.
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant emergency protocols at the point of need
Wider context from the report “(3) The site manager was new and although there had been some training for her role, there was a lack of understanding of the emergency protocols and this was also the case with nurses at the hospital for this event. A very senior member of the ambulance crew was attempting to assist the site co-ordinator as to locate the most relevant documents . Training needs to be embedded and protocols readily available .
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Lack of plan for transfer to a tertiary centre
Wider context from the report “(4) There was some confusion about the roles and responsibilities when there was a concern that an ambulance was required to attend to a major event to a private hospital where the patient was undergoing surgery in an operating theatre. Evidence was that Mrs Pytches was suffering from a major haemorrhage with an uncertain aetiology. There is a concern that Mrs Pytches did not regain stability such that she could have been safely moved and there was no plan as to whether Mrs Pytches required transfer to a tertiary centre . Calling an ambulance without an understanding of specifically what was required could impact on a future death taking this resource from a community emergency. Mrs Pytches already had the attendance of qualified surgeons and anaesthetists whilst suffering a major haemorrhage that could not be treated by community paramedics, however well qualified and experienced as in this case.
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Lack of process for doctors to notify private hospital management of practice limitations
Wider context from the report “(1) An Anaesthetist who responded to an emergency crash call had limitations on his ability to participate in resuscitation. These limitations had been declared to his team on the day but had not been shared with the Hospital Management where he was participating in surgery. The Hospital Management did not have an opportunity to consider the limitations on the Doctor’s practice as a part of a risk assessment and to ensure that the limitations were acceptable in all the circumstances and that any potential risks mitigated. There is no requirement or process for doctors to notify their limitations to the private hospital management.
” 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 Clarify ambulance-activation responsibilities during theatre emergencies in local standard operating policies and emergency guides.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
Verbatim wording from the response “• Ongoing monitoring will be undertaken through existing audit and assurance processes, including Interim Quality Assurance Report requirements, scenario dashboards, and governance reviews.” Source location Response from Nuffield Health
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 Reinforce ambulance-activation pathways through simulation covering deterioration recognition, escalation, intervention, ambulance arrival and SBARD handover.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 Use policy-access and readership analytics to assure Consultant and staff engagement with critical emergency documentation.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 Consultant induction and practising-privileges renewal checklists to require notification of temporary or permanent practice limitations, including same-day changes.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 induction and practising-privileges renewal checklists to cover MyStaff access and locating local emergency policies.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 MyStaff as a centralised platform for accessible Group and local policies, update alerts and critical-policy readership analytics.
Verbatim wording from the response “• Nuffield has implemented MyStaff, a centralised policy management system providing real-time access to Group-level and local policies via desktop and secure mobile application. We are the first independent provider to have done this. This ensures policies are more accessible at the point of care and that users are alerted when documents are updated. Phase 1 (launched November 2025) migrated all Group policies and associated documents to the platform. Phase 2 (launched April 2026) introduced analytics to monitor readership of critical policies, strengthening assurance and enabling targeted follow-up. All staff and Consultants have 24/7 access to policies via the MyStaff app (on and off site).” Source location Response from Nuffield Health
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 Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Verbatim wording from the response “• Emergency reference guides are consistently available across all departments and include guidance for cardiac arrest and major haemorrhage in line with Nuffield Health Policy CL71 Medical Emergencies and Resuscitation Council guidelines. The availability, accessibility and use of these guides are routinely reviewed and reinforced through regular emergency scenario training and simulations to ensure staff familiarity and effective application in practice. Laminated emergency algorithms, including adult major haemorrhage pathways, are located on resuscitation trolleys and in key clinical areas.” Source location Response from Nuffield Health
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 Require explicit confirmation of workload, wellbeing and safe scope of practice in Consultant practising-privileges renewals.
Verbatim wording from the response “Actions / Measures already in place across all Nuffield Health hospitals:” Source location Response from Nuffield Health
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 Use SBARD as a decision-support tool for escalation and transfer discussions.
Verbatim wording from the response “Actions / Measures already in place across all Nuffield Health hospitals:” Source location Response from Nuffield Health
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 Roll out mandatory emergency-protocol induction for site leaders, night coordinators and senior nursing staff, including role responsibilities.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 Incorporate tertiary-referral criteria and senior clinician-to-ambulance communication into scenario-based training.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 Further develop the major-haemorrhage training module to clarify end-to-end processes and differences from NHS pathways.
Verbatim wording from the response “Further actions across Nuffield Health:” Source location Response from Nuffield Health
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 Regulation 28 concerns did not contribute to the patient’s death.
Verbatim wording from the response “HM Coroner specifically noted that the Regulation 28 concerns did not contribute to this patient death.” Source location Response from Nuffield Health
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 All staff, including the site manager, had received training on the transfusion and major haemorrhage policies in force at the time.
Verbatim wording from the response “• The site manager was new to the role but previously held a Senior clinical role as head of department in the Hospital for 9 years prior.” Source location Response from Nuffield Health
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 Calling emergency services was an appropriate response because transfer to an NHS facility providing Level 3 care would have been required.
Verbatim wording from the response “• Emergency services were called to enable an urgent transfer of Mrs Pytches to an NHS facility that could provide Level 3 care. This was an appropriate emergency response for the critical clinical situation, where the Hospital did not have on site Intensive Treatment Unit facilities. A transfer would have been required if Mrs Pytches had survived and it was prudent and reasonable to make sure that this was available at the earliest possible opportunity.” Source location Response from Nuffield Health
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 Practising Privileges Policy already required doctors to notify hospital management of health limitations affecting practice or patient safety.
Verbatim wording from the response “• The concern related to a third Consultant anaesthetist who was requested to assist with the arrest and who was working in different operating theatre. He had informed his theatre team of limitations relating to musculo skeletal condition which meant that he was not physically able to assist with resuscitation. However, he had not followed due process by declaring this limitation to the hospital management team earlier.” Source location Response from Nuffield Health
Open published response
10 May 2021 Mr. John Charles LOTT · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Failure to sufficiently highlight the transfer policy to nursing staff and Resident Medical Officers View source Failure to manage hypoglycaemia View source Failure to contact the on-call anaesthetist for input and support when the consultant is unavailable View source Failure to transfer patients requiring higher-level care to appropriate critical care facilities View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr. John Charles LOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Lott underwent surgery to form a defunctioning ileostomy and subsequently became seriously unwell, including inadequately treated hypoglycaemia, myocardial ischaemia and infarction. He died on 8 November 2020 after two occasions when transfer from the private hospital to an NHS hospital with appropriate critical care facilities was considered necessary but did not occur. Concerns included missed transfer opportunities, inadequate management of hypoglycaemia, and a lack of contact with the on-call anaesthetist when the consultant was unavailable.
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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently highlight the transfer policy to nursing staff and Resident Medical Officers
Wider context from the report “(3) When ████████ the Consultant “in charge” of Mr. Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support. Why not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers?
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to manage hypoglycaemia
Wider context from the report “(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield.
(2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed . He should have been transferred.
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the on-call anaesthetist for input and support when the consultant is unavailable
Wider context from the report “(3) When ████████ the Consultant “in charge” of Mr. Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support . Why not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers?
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients requiring higher-level care to appropriate critical care facilities
Wider context from the report “(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield .
(2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred .
” Open source report
8 Oct 2019 Mary Jane Chapman · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Lack of guidance for arranging and communicating critical post-discharge investigations View source Lack of a defined multidisciplinary approach to risk assessing low platelet count patterns View source Failure to ensure clinical and nursing staff awareness of individual discharge responsibilities View source Failure to clearly define responsibilities and timings in the discharge process View source Failure to demonstrate effective risk management of patients with low platelet counts View source Failure to ensure doctors document intended follow-up investigation plans View source Failure to ensure clear and unambiguous procedures for implementing post-discharge investigation decisions View source Failure to demonstrate effective discharge communications View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Jane Chapman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Jane Chapman underwent elective knee replacement surgery and was discharged with a low platelet count, but a required follow-up blood test was not arranged. She was later admitted with a dangerously low platelet count and died on 4 March 2018 from a large myocardial infarction caused by coronary artery thrombosis associated with catastrophic antiphospholipid syndrome. The principal concerns related to unclear discharge responsibilities and procedures, inadequate communication and documentation of critical follow-up investigations, and insufficient evidence that subsequent changes had improved these processes.
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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for arranging and communicating critical post-discharge investigations
Wider context from the report “2) There is no clear local or Nuffield-wide guidance document or policy on how the need for critical post-discharge investigations should be arranged or communicated, or by whom or when ;
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined multidisciplinary approach to risk assessing low platelet count patterns
Wider context from the report “5) The inquest heard that it is accepted that there is a need for a multi-disciplinary team approach to risk assessing patterns with low platelet counts, but there was no document or policy addressing this new approach . There was no evidence of how such an approach should work in practice and there was no evidence to demonstrate that the new approach has improved the risk management of such patients;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinical and nursing staff awareness of individual discharge responsibilities
Wider context from the report “3) In respect of (1) and (2) above there was no evidence at the inquest that clinical and nursing staff are now aware of their individual roles and responsibilities in the discharge process , other than as part of a new induction process, which self-evidently only captures new staff . Equally, despite 18 months having elapsed since the death, there was no evidence at the inquest to demonstrate that such changes as have been implemented have improved the quality, accuracy and robustness of discharge communications;
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly define responsibilities and timings in the discharge process
Wider context from the report “1) Although a Nuffield-wide ‘discharge policy’ has been created, the document is lengthy, unwieldy and generic. It does not clearly define who is responsible for doing what, or when, as part of the discharge process and there is no clear local or Nuffield-wide guidance document or policy that achieves this ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate effective risk management of patients with low platelet counts
Wider context from the report “5) The inquest heard that it is accepted that there is a need for a multi-disciplinary team approach to risk assessing patterns with low platelet counts, but there was no document or policy addressing this new approach. There was no evidence of how such an approach should work in practice and there was no evidence to demonstrate that the new approach has improved the risk management of such patients ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors document intended follow-up investigation plans
Wider context from the report “4) The inquest heard evidence that, since the death, the need for doctors to fully document their intended plan for follow-up investigations in the notes has been reinforced . Despite the importance of this as part of the discharge process, there was no evidence to demonstrate that this has resulted in improved record keeping or that the same has resulted in more robust and accurate discharge communications;
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear and unambiguous procedures for implementing post-discharge investigation decisions
Wider context from the report “6) The fact that Nuffield is a private hospital means that the doctors working there are likely to come from a variety of different hospitals and will be used to a variety of different working practices. Whilst the decision about what post-discharge investigations are required is clearly a matter of clinical judgment, the responsibility for ensuring that clear and unambiguous procedures exist to implement those clinical decisions lies with the Nuffield .
” 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 Nuffield Health; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate effective discharge communications
Wider context from the report “3) In respect of (1) and (2) above there was no evidence at the inquest that clinical and nursing staff are now aware of their individual roles and responsibilities in the discharge process, other than as part of a new induction process, which self-evidently only captures new staff. Equally, despite 18 months having elapsed since the death, there was no evidence at the inquest to demonstrate that such changes as have been implemented have improved the quality, accuracy and robustness of discharge communications ;
” 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 Test and roll out an electronic quality-management audit across hospitals to monitor discharge-process effectiveness and patient experience.
Verbatim wording from the response “3) The role & responsibilities of all professionals working within the multidisciplinary clinical team are clear within the revised policy and an audit process, which is currently being tested, will be used across all hospitals to monitor the efficacy of the process and the patient experience. This audit is on our electronic Quality Management System (QMS). The list of questions that make up the audit are attached at Appendix C but please note that this does not show the on-line format which is user-friendly with clear headings. Section 7 onwards of the audit is of particular relevance” Source location 2019-0360-Response-by-Nuffield-Health
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 consultants’ responsibilities for contemporaneous documentation and discharge-related communication with nursing staff and GPs.
Verbatim wording from the response “4) Every medical practitioner working within Nuffield Hospitals received a communication:” Source location 2019-0360-Response-by-Nuffield-Health
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 Rewrite the national discharge policy to clarify multidisciplinary roles, responsibilities, discharge scenarios and arrangements for critical post-discharge investigations.
Verbatim wording from the response “1) The revised Nuffield Health Policy (Appendix B) is rewritten paying particular attention to clarity of role and responsibilities associated with different professionals within the multidisciplinary team, with regard to the patient discharge process. The process itself has greater clarity and considers all scenarios that may present for patients using Nuffield Health services.” Source location 2019-0360-Response-by-Nuffield-Health
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 Monitor anaesthetic records through the established audit programme to verify that abnormal results are highlighted.
Verbatim wording from the response “With regard to abnormal platelet counts in the event of no known diagnosis of APS, we know from the investigation that the nursing team correctly escalated the low platelet count noted at POA, which is consistent with Nuffield Health Policy. For ongoing assurance, our established audit programme includes monitoring anaesthetic records to ensure abnormal results are highlighted.” Source location 2019-0360-Response-by-Nuffield-Health
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 secure electronic discharge-summary delivery to provide GP surgeries with heightened assurance of receipt within 48 hours.
Verbatim wording from the response “Another key development in the Hospital was the introduction of electronic issue of discharge summaries via a secure portal, to give heightened assurance that information is received into GP surgeries within 48hrs of patient discharge. This system is in place in a small number of Nuffield Hospitals and we are looking to extend across all 31 locations. We now recognise further opportunities to improve quality and consistency of the discharge process through standardisation of systems, process and collaborative working with GP’s, which we are taking forward in our Quality Improvement Plan.” Source location 2019-0360-Response-by-Nuffield-Health
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 Distribute RMO discharge-communication guidance, event learning, escalation criteria and antiphospholipid syndrome information.
Verbatim wording from the response “Actions agreed and completed within 4 weeks were:” Source location 2019-0360-Response-by-Nuffield-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the RMO induction and handbook to strengthen responsibilities for escalating abnormal results and documenting communications.
Verbatim wording from the response “▪ The clinical team at Nuffield Health reviewed the RMO Induction and Handbook to strengthen the emphasis on the above responsibilities (Appendix G (1 and 2)).” Source location 2019-0360-Response-by-Nuffield-Health
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 Contact GPs by telephone, in addition to sending discharge summaries, when urgent action is required.
Verbatim wording from the response “Immediately following Mary’s death, a local investigation took place at the Hospital with significant changes to mitigate future risk. This included the introduction of an additional step in Nuffield’s” Source location 2019-0360-Response-by-Nuffield-Health
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 Advance a quality-improvement plan for standardised discharge systems, processes and collaborative working with GPs.
Verbatim wording from the response “Another key development in the Hospital was the introduction of electronic issue of discharge summaries via a secure portal, to give heightened assurance that information is received into GP surgeries within 48hrs of patient discharge. This system is in place in a small number of Nuffield Hospitals and we are looking to extend across all 31 locations. We now recognise further opportunities to improve quality and consistency of the discharge process through standardisation of systems, process and collaborative working with GP’s, which we are taking forward in our Quality Improvement Plan.” Source location 2019-0360-Response-by-Nuffield-Health
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations