Concerns raised 4 Lack of policy, guidance or standard operating procedure for processing medical reports received from other hospitals View source Failure to report errors through the OUH Incident Reporting process View source Decisions to proceed with major operations without the surgical team having full knowledge of disease progression View source Failure to investigate errors to establish why they happened and prevent recurrence View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
June Thompson · 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
June Thompson died on 1 November 2023 from radiation-induced metastatic sarcoma following radiotherapy for cervical cancer. She underwent a hindquarter amputation after a CT scan showed that the cancer had spread to her lungs, but the surgical team and multidisciplinary team were not informed of the change from a potentially curative to a palliative condition. Concerns included proceeding with major operations without full knowledge of disease progression, failure to report and investigate the error, and the absence of policy or guidance for processing medical reports received from other hospitals.
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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy, guidance or standard operating procedure for processing medical reports received from other hospitals
Wider context from the report “• There is no policy, guidance or standard operating procedure regarding how to process medical reports being received at OUH from other hospitals .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report errors through the OUH Incident Reporting process
Wider context from the report “• The error has not been reported through the OUH Incident Reporting 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Decisions to proceed with major operations without the surgical team having full knowledge of disease progression
Wider context from the report “• There is a risk of future deaths from decisions to proceed with major operations without the surgical team having full knowledge of disease progression , this could include operations that may be unnecessary.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate errors to establish why they happened and prevent recurrence
Wider context from the report “• The error has not been investigated to establish why it happened and how to prevent a reoccurrence .
” 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 Feed back to the Sarcoma team the importance of reporting all patient safety incidents, including no-harm incidents.
Verbatim wording from the response “We acknowledge that the incident was not reported in our incident reporting system until after the inquest. The Sarcoma service has an open and transparent reporting culture as evidenced by 37 incidents that have been reported in the last 2 years with 26 of these being of ‘no harm’. We have fed back to the team the importance of reporting any patient safety incidents and will send a Trust wide Safety Message emphasising the importance of reporting all safety incidents including ‘no harm’ (previously known as ‘near misses’) to ensure learning to prevent future harm.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report and investigate the incident under the Patient Safety Incident Response Framework.
Verbatim wording from the response “The incident has now been reported and investigated in line with the Trust’s implementation of the Patient Safety Incident Response Framework. The learning from the inquest and this investigation has been highlighted at the Trust-wide Safety Learning and Improvement Conversation and circulated to all clinical teams. It will also be presented at the next Sarcoma Surgery Clinical Governance meeting, Trust Clinical Governance Committee and the OUH Mortality Review Group over the next 2 months.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute the revised pelvic surgery SOP to surgical consultants and share it with Surgery Clinical Leads.
Verbatim wording from the response “In addition, a separate SOP for the Oxford Radical Pelvic Surgical team has been revised to include a prompt to check for test result reports from external NHS Trusts before proceeding to treatment. If test results are requested within OUH then the Electronic Patient Record already automatically notifies the test requestor and the named consultant of the result. The updated SOP has been distributed to all pelvic surgical consultants and will be shared with Clinical Leads for Surgery for learning across the Trust. I attach a copy of this clinical SOP.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Oxford Radical Pelvic Surgical team SOP to require checking external NHS test-result reports before treatment.
Verbatim wording from the response “In addition, a separate SOP for the Oxford Radical Pelvic Surgical team has been revised to include a prompt to check for test result reports from external NHS Trusts before proceeding to treatment. If test results are requested within OUH then the Electronic Patient Record already automatically notifies the test requestor and the named consultant of the result. The updated SOP has been distributed to all pelvic surgical consultants and will be shared with Clinical Leads for Surgery for learning across the Trust. I attach a copy of this clinical SOP.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate a Trust-wide patient safety message requiring staff to review radiology reports before surgery.
Verbatim wording from the response “The learning from this inquest and the subsequent investigation (see below) was highlighted at the Trust wide Safety Learning and Improvement Conversation on 17 April 2025 and the key learning of communicating test and scan results performed outside OUH to the named consultant was included in the summary slide from this meeting which was circulated to all clinical teams. A Trust wide Patient Safety Message email highlighting the importance of reviewing all radiology reports prior to surgery has been drafted and will be circulated to all OUH staff in the next 4 weeks.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the learning that external test and scan results must be communicated to named consultants to all clinical teams.
Verbatim wording from the response “The learning from this inquest and the subsequent investigation (see below) was highlighted at the Trust wide Safety Learning and Improvement Conversation on 17 April 2025 and the key learning of communicating test and scan results performed outside OUH to the named consultant was included in the summary slide from this meeting which was circulated to all clinical teams. A Trust wide Patient Safety Message email highlighting the importance of reviewing all radiology reports prior to surgery has been drafted and will be circulated to all OUH staff in the next 4 weeks.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send a Trust-wide safety message emphasising reporting all patient safety incidents, including no-harm incidents.
Verbatim wording from the response “We acknowledge that the incident was not reported in our incident reporting system until after the inquest. The Sarcoma service has an open and transparent reporting culture as evidenced by 37 incidents that have been reported in the last 2 years with 26 of these being of ‘no harm’. We have fed back to the team the importance of reporting any patient safety incidents and will send a Trust wide Safety Message emphasising the importance of reporting all safety incidents including ‘no harm’ (previously known as ‘near misses’) to ensure learning to prevent future harm.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the new SOP for managing clinical information received from other departments, NHS trusts and organisations across the Trust.
Verbatim wording from the response “To address this risk across the Trust, a new Standard Operating Protocol (SOP) has been developed for Management of Patient Related Clinical Information received from another Department / Trust / Organisations. I attach a copy of this SOP which has already been implemented in the gynaecology and sarcoma services and is being rolled out across the Trust.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
9 Jan 2025 David Vincent Tighe · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 4 Unavailability of Ryles tube repeat-position-check records View source Absence of a specific policy for management of Ryles tubes View source Use of narrowly scoped and time-pressured structured reviews of incidents View source Use of incident reviewers with potential conflicts of interest View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Vincent Tighe · 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 Vincent Tighe, a 59-year-old man receiving chemotherapy for cancer, was admitted to hospital with chemotherapy-induced enterocolitis. During his treatment, bile aspiration occurred after insufficient monitoring and displacement of a Ryles tube, contributing to bronchopneumonia and sepsis, from which he died. The principal concerns were the absence of a specific Ryles tube policy and the use of a narrowly focused structured review that could miss care or procedural problems.
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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Ryles tube repeat-position-check records
Wider context from the report “Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice.
Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death.
Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed .
Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring.
At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023.
It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required.
The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure.
Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment.
The Structured Review consequently overlooked considering several issues including:
(i) missing bile drainage entries.
(ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021).
(iii) the absence of Repeat Position Checks for the Ryles tube.
(iv) the absence of any written record of family concerns that were raised with a ward sister.
Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review.
That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance.
Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a specific policy for management of Ryles tubes
Wider context from the report “Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes , and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice .
Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death.
Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed.
Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring.
At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023.
It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required.
The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure.
Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment.
The Structured Review consequently overlooked considering several issues including:
(i) missing bile drainage entries.
(ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021).
(iii) the absence of Repeat Position Checks for the Ryles tube.
(iv) the absence of any written record of family concerns that were raised with a ward sister.
Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review.
That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance.
Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of narrowly scoped and time-pressured structured reviews of incidents
Wider context from the report “Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice.
Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death.
Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed.
Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring.
At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023.
It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required.
The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure.
Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus , as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff , but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment .
The Structured Review consequently overlooked considering several issues including:
(i) missing bile drainage entries.
(ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021).
(iii) the absence of Repeat Position Checks for the Ryles tube.
(iv) the absence of any written record of family concerns that were raised with a ward sister.
Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review.
That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance.
Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure , and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of incident reviewers with potential conflicts of interest
Wider context from the report “Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice.
Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death.
Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed.
Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring.
At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023.
It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required.
The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure.
Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment.
The Structured Review consequently overlooked considering several issues including:
(i) missing bile drainage entries.
(ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021).
(iii) the absence of Repeat Position Checks for the Ryles tube.
(iv) the absence of any written record of family concerns that were raised with a ward sister.
Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review.
That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance.
Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias , creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
” 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 Present and publish the Ryles tube policy and communicate it to all staff through a Trust-wide safety message.
Verbatim wording from the response “The Oncology Matron has set up a working group to review current practice, evaluate external resources and produce a Trust wide policy. The policy will set out the Trust standards for managing patients with Ryles Tubes for aspiration drainage. The working group includes nursing and medical staff across the organisation including anaesthetics, surgery, oncology and gastroenterology representatives. The first meeting was held on 3 February 2025. The policy will be presented to the OUH Clinical Policy Group by April 2025 and a Trust wide safety message will be communicated to all staff which will include the link to this policy. The publication of the policy will be followed by training of the appropriate staff through ward-based learning delivered by clinical educators.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require reviewers to confirm before completing a Structured Judgement Review whether they have a conflict of interest.
Verbatim wording from the response “Secondly, we have modified the SJR template to ask the author if they have any concerns about the scope or focus of the review, giving them an explicit opportunity to raise any concerns which can then be addressed proactively by the Trust through providing additional support. Prior to completing the review, the reviewer will also be asked to confirm whether they have any conflict of interest such as having been involved in the care of the patient. This will provide stronger assurance that all reviews investigate deaths without restriction in scope, time pressure or appearance of conflict or bias.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify the Structured Judgement Review template to prompt reviewers to identify concerns about the review’s scope or focus.
Verbatim wording from the response “Secondly, we have modified the SJR template to ask the author if they have any concerns about the scope or focus of the review, giving them an explicit opportunity to raise any concerns which can then be addressed proactively by the Trust through providing additional support. Prior to completing the review, the reviewer will also be asked to confirm whether they have any conflict of interest such as having been involved in the care of the patient. This will provide stronger assurance that all reviews investigate deaths without restriction in scope, time pressure or appearance of conflict or bias.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review current practice and develop a Trust-wide policy for managing Ryles tubes used for aspiration drainage.
Verbatim wording from the response “There is no nationally recognised policy for wide bore nasogastric (Ryles) tubes for aspiration drainage. The existing OUH policy is for nasogastric (NG) tubes when used for feeding. Current practice for insertion of a wide bore tube is based on the Royal Marsden manual of clinical and cancer nursing procedures. Only one of the 9 similar Trusts who we approached has a policy which is virtually identical to the Royal Marsden manual.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing Structured Judgement Review process requires whole-record review, allows sufficient time, and enables concerns about care quality to be escalated.
Verbatim wording from the response “The Trust has a robust process for training clinicians in performing Structured Judgement Reviews (SJRs). The training highlights the need to review the whole case record including the nursing records. It directs the reviewer to contact any individual or team if there are concerns about the quality of care provided. There is no limit put on the length of time to undertake an SJR. Over 230 clinicians within OUH have been trained to date.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
Open published response
12 Jun 2024 Beryl Dandridge · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Inconsistent and inappropriate decision-making about preoperative echocardiograms and delaying periprosthetic surgery View source Failure to include relevant anaesthetic subject expertise in Structured Mortality Reviews View source Unclear responsibility for expediting required echocardiograms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Beryl Dandridge · 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
Beryl Dandridge fell at her nursing home on 23 January 2024 and sustained a periprosthetic hip fracture. Her ambulance attendance and surgery were delayed, including a delay while an echocardiogram was considered necessary; she underwent surgery on 27 January and died on 28 January 2024. Concerns related to conflicting clinical views about the need for echocardiography, responsibility for expediting it, and the subject expertise involved in the structured mortality review.
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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and inappropriate decision-making about preoperative echocardiograms and delaying periprosthetic surgery
Wider context from the report “1. As part of the evidence, it became clear there were conflicting views between clinicians regarding the need for an echocardiogram for vulnerable patients pending periprosthetic surgery and the circumstances when surgery might be appropriately delayed pending such a scan . Evidence was heard that the Anaesthetists of Great Britain and Ireland (AAGBI) guidelines regarding echocardiograms (which apply to higher risk surgery more generally) were incorrectly applied to the circumstances of Mrs Dandridge’s periprosthetic fracture.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include relevant anaesthetic subject expertise in Structured Mortality Reviews
Wider context from the report “3. The Structured Mortality Review was critical of the decision to require an echocardiogram pending surgery. Such a review is designed to provide learning for the Trust to be applied in future cases. The evidence at the Inquest was that the Review had no input from an anaesthetist who may have articulated the medical justification for such an echocardiogram in this instance. Concerns were raised in evidence that without the relevant subject expertise at such Reviews any future learning from a Structured Mortality Review could be inaccurate or misconceived .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for expediting required echocardiograms
Wider context from the report “2. Having determined that an echocardiogram was required before surgery could take place, it was unclear which clinicians was responsible for expediting such a scan in circumstances where the evidence indicated that delays in surgery is associated with poorer outcomes for vulnerable patients.
” 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 Ensure Mortality Review Groups include appropriate subject-matter expertise and convene wider Learning MDT meetings when needed.
Verbatim wording from the response “The OUH Mortality Review Process includes dedicated training for senior clinicians in conducting Structured Mortality Reviews (SMR). SMRs are presented to the Trust Mortality Review Group which is composed of a range of consultants. The SMR discussion for this case did involve an anaesthetist when it was presented at MRG. We have strengthened the SMR training, guidance and report template to include a requirement to discuss any concerns about poor clinical care raised in the SMR with the appropriate clinician involved and to include their views within the SMR as necessary. The Mortality Review Group will ensure that subject matter expertise is included in all cases, especially where there are concerns about the quality of care provided and if necessary a wider Learning MDT meeting with a range of subject matter experts will be convened to explore any differences of opinion.” Source location Response from Oxfordshire County Council
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 Clarify and agree the urgent echocardiogram process, including criteria, responsibilities, timescales, multidisciplinary discussion and escalation.
Verbatim wording from the response “We already have a process for requesting urgent echocardiograms within the Trust. This process was reviewed and clarified at the Learning Multi-disciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant Cardiology team and the escalation will go through the on call Consultant Cardiologist.
Some members of the Orthogeriatrics team will also undergo training in focused bedside echocardiography to provide further capacity for urgent echocardiograms.” Source location Response from Oxfordshire County Council
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 Strengthen Structured Mortality Review training, guidance and reporting templates to capture relevant clinicians’ views on concerns about poor care.
Verbatim wording from the response “The OUH Mortality Review Process includes dedicated training for senior clinicians in conducting Structured Mortality Reviews (SMR). SMRs are presented to the Trust Mortality Review Group which is composed of a range of consultants. The SMR discussion for this case did involve an anaesthetist when it was presented at MRG. We have strengthened the SMR training, guidance and report template to include a requirement to discuss any concerns about poor clinical care raised in the SMR with the appropriate clinician involved and to include their views within the SMR as necessary. The Mortality Review Group will ensure that subject matter expertise is included in all cases, especially where there are concerns about the quality of care provided and if necessary a wider Learning MDT meeting with a range of subject matter experts will be convened to explore any differences of opinion.” Source location Response from Oxfordshire County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt individualized risk assessment for patients with periprosthetic femoral fractures.
Verbatim wording from the response “The Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines on the management of hip fractures (2020) are not explicitly for the type of fracture that Mrs Dandridge experienced (distal peri-prosthetic femur fracture). However they are used as a guide for all fragility femoral fractures by the Orthogeriatrician Team.
We convened a group of experts at the Learning Multi-disciplinary Team meeting including the Orthogeriatrician team and the Anaesthetist involved in this case and have agreed that whilst some of the same principles of the AAGBI guidelines apply to patients with periprosthetic fractures as to other femoral fragility fractures, these cases present a more complex risk / benefit analysis due to the increased length of operation and complexity of the surgery and therefore each patient will require an individualised risk assessment.” Source location Response from Oxfordshire County Council
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 An existing Trust process governs urgent echocardiogram requests, including responsibility, timescales, multidisciplinary discussion and escalation.
Verbatim wording from the response “We already have a process for requesting urgent echocardiograms within the Trust. This process was reviewed and clarified at the Learning Multi-disciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant Cardiology team and the escalation will go through the on call Consultant Cardiologist.
Some members of the Orthogeriatrics team will also undergo training in focused bedside echocardiography to provide further capacity for urgent echocardiograms.” Source location Response from Oxfordshire County Council
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 AAGBI hip-fracture guidelines are not explicitly applicable to periprosthetic femur fractures, which require individualized risk assessment.
Verbatim wording from the response “The Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines on the management of hip fractures (2020) are not explicitly for the type of fracture that Mrs Dandridge experienced (distal peri-prosthetic femur fracture). However they are used as a guide for all fragility femoral fractures by the Orthogeriatrician Team.
We convened a group of experts at the Learning Multi-disciplinary Team meeting including the Orthogeriatrician team and the Anaesthetist involved in this case and have agreed that whilst some of the same principles of the AAGBI guidelines apply to patients with periprosthetic fractures as to other femoral fragility fractures, these cases present a more complex risk / benefit analysis due to the increased length of operation and complexity of the surgery and therefore each patient will require an individualised risk assessment.” Source location Response from Oxfordshire County Council
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 Mortality Review Process already includes relevant clinical expertise through trained clinicians, consultant review and subject-matter input where necessary.
Verbatim wording from the response “The OUH Mortality Review Process includes dedicated training for senior clinicians in conducting Structured Mortality Reviews (SMR). SMRs are presented to the Trust Mortality Review Group which is composed of a range of consultants. The SMR discussion for this case did involve an anaesthetist when it was presented at MRG. We have strengthened the SMR training, guidance and report template to include a requirement to discuss any concerns about poor clinical care raised in the SMR with the appropriate clinician involved and to include their views within the SMR as necessary. The Mortality Review Group will ensure that subject matter expertise is included in all cases, especially where there are concerns about the quality of care provided and if necessary a wider Learning MDT meeting with a range of subject matter experts will be convened to explore any differences of opinion.” Source location Response from Oxfordshire County Council
Open published response
27 Oct 2023 Francis Osborne Barnes · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Failure to identify proposed changes after a death View source Failure to record multidisciplinary team meeting minutes View source Failure to engage with other organisations to learn jointly from events View source Failure to investigate deaths and co-operate in joint investigations View source Failure to record morbidity and mortality meeting minutes View source Failure to record vascular surgery consultations View source Unclear vascular surgery referral pathways View source See 4 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
Francis Osborne Barnes · 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
Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify proposed changes after a death
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death .
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record multidisciplinary team meeting minutes
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute , although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with other organisations to learn jointly from events
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored .
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored . The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate deaths and co-operate in joint investigations
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record morbidity and mortality meeting minutes
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute , although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record vascular surgery consultations
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved , despite being consulted several times about the same patient in a short space of time , and the fact that there was a clinical difference of opinion about where the patient should best be managed .
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear vascular surgery referral pathways
Wider context from the report “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death.
I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust.
The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital.
There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed.
There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed.
There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death.
Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored.
It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned.
Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways , and use of an OARS system (or similar).
No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed.
We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason.
The matters of concern can be summarised as follows:
1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector).
2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients.
3. Consideration of how the Oxford Trust responds to and learns from deaths.
” 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 Maintain the OUH Medical Examiner office to scrutinize all non-Coronial deaths and feed concerns to governance and clinical teams.
Verbatim wording from the response “3.2.3 OUH introduced the Medical Examiner (ME) office in June 2020. This is to provide greater safeguards for the public by ensuring proper scrutiny of all non-Coronial deaths. Currently 100% of Trust deaths are reviewed by the ME office who feedback any concerns directly to the Learning from Deaths team (part of the Clinical Governance team). Any concerns and compliments are also fed back to clinical teams for action.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the approved vascular emergency referral procedure to NHS and private Thames Valley providers.
Verbatim wording from the response “1.1 Following this inquest, a concise procedure for contacting the Vascular Team at OUH has been developed and approved by the TVVN which clearly sets out the referral process for patients who have a vascular emergency within the network. This will be sent to all NHS and private providers in Thames Valley and provides details on how to contact the on-call Vascular SpR and on-call Vascular Consultant.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the OUH Vascular Surgery monthly morbidity and mortality meeting to discuss non-OUH vascular-related deaths.
Verbatim wording from the response “3.1.4 The OUH Vascular Surgery monthly M&M meeting currently reviews all vascular deaths that occur within OUH. This meeting will be amended to discuss non-OUH vascular related deaths to enable learning to be disseminated within OUH.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appraise options for documenting TVVN vascular referrals and consultant advice.
Verbatim wording from the response “2. Consideration of an electronic referral system” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the OUH Mortality Review Policy with an appendix governing cross-system learning responses across the BOB ICB and Frimley.
Verbatim wording from the response “3.2.8 In response to this inquest several new processes have also been introduced:” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.
Verbatim wording from the response “3.1 Future Governance of cross-organisational incidents within TVVN” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a weekly Patient Safety meeting with the BOB ICB to coordinate multi-organisational incident planning and progress.
Verbatim wording from the response “3.2.8.2 A weekly Patient Safety meeting with Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care Board (ICB) has been established for Patient Safety Teams to plan and liaise on the progress of multi-organisational Patient Safety Incidents. Ad-hoc arrangements can also be made in the event of significant Patient Safety incidents that require urgent planning and response.” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Microsoft 365 Form to document emergency vascular referrals from across the TVVN.
Verbatim wording from the response “2.3.1 The use of a Microsoft 365 Form which will enable all referrals to be documented in real time including a record of the patient’s name and NHS number. This does not require the patient to have an existing OUH medical record number (MRN) and so allows documentation of referrals of patients who are not currently under the care of OUH. This Form is currently used by the vascular surgical team to track patients from around the region who are awaiting discussion at the Multidisciplinary Team meetings. The data is stored within the OUH server on Sharepoint.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and approve a concise TVVN vascular emergency referral procedure.
Verbatim wording from the response “1. Clarification of vascular surgery hub pathways” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce three forms for documenting vascular surgery-related concerns about patient deaths in the Thames Valley.
Verbatim wording from the response “3.1.2 The M&M documentation will include three new forms which will require completion whenever there is a vascular surgery-related concern raised about a patient death in the Thames Valley region.” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing clinical audit and research system cannot document referrals across the network because it requires an existing OUH electronic patient record.
Verbatim wording from the response “2.3.2 A clinical audit and research system is currently used to document every inpatient encounter and vascular operation within Vascular Surgery in OUH. It could be used to document referrals to the vascular service; however, it is dependent on the patient having an existing OUH Electronic Patient Record (EPR) and so would not be suitable for documenting referrals from across the TVVN.” Source location Response from Oxford University Hospitals NHS Foundation Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone referral to the on-call vascular team is considered more timely and effective than any electronic referral system for vascular emergencies.
Verbatim wording from the response “2.2 The TVVN have agreed that all vascular emergencies should continue to be referred by telephone to the on-call vascular surgical team at OUH. No electronic referral system would ensure as timely and effective a response to vascular emergencies.” Source location Response from Oxford University Hospitals NHS Foundation Trust
Open published response
25 Nov 2021 Saif Mubeen Hussain · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of appropriate limits on the administration of certain drugs View source Limited implementation of medication-safety software View source Failure to define and document overrides of medication-safety software View source Lack of a system for flagging discrepancies between drug prescription and administration View source Lack of a single system for record keeping and monitoring 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
Saif Mubeen Hussain · 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
Saif Mubeen Hussain died at John Radcliffe Hospital on 10 June 2021 after being admitted following an incident in Bracknell, Berkshire, on 3 June 2021; the recorded cause of death was polytrauma. During his transfer between units, he was administered a Heparin infusion at almost eight times the prescribed rate. The report identified concerns about unfamiliarity with anticoagulants, inadequate double-checking, the Guardrails system being switched off, differences between prescription and administration rates not being flagged, and the use of separate hospital computer systems.
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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate limits on the administration of certain drugs
Wider context from the report “2. How the system could incorporate appropriate limits on the administration of certain drugs within that system.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited implementation of medication-safety software
Wider context from the report “3. Whether software like Guardrails should be implemented more widely , and consideration given to when and how it is possible to override this, and how that should then be documented.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define and document overrides of medication-safety software
Wider context from the report “3. Whether software like Guardrails should be implemented more widely, and consideration given to when and how it is possible to override this , and how that should then be documented .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for flagging discrepancies between drug prescription and administration
Wider context from the report “4. Adopting a system of flagging up where prescription and administration of drugs is different .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a single system for record keeping and monitoring
Wider context from the report “1. A single system for record keeping and monitoring.
” 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 Educate staff to use medication libraries and not bypass safety limits except in exceptional circumstances.
Verbatim wording from the response “Each medication library will contain a list of medications with specified concentrations and/or dosing safety limits to reduce the risk of infusion related incidents e.g., overdosing or underdosing. Resource will be allocated to ensure that medication entries on the libraries are accurate, relevant, and appropriate so that staff should not need to override safety limits if following usual practice; the software is designed not to be overridden if inappropriate dosing is entered outside of the safe limits put in place.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_Published
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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 dose-error-reduction infusion pumps and medication libraries across all clinical areas, with specified concentrations and dosing safety limits.
Verbatim wording from the response “The Trust is in the process of implementing infusion pumps with inbuilt dose error reduction software (DERS) throughout all clinical areas. Once the project has successfully been completed, clinical areas which use infusion pumps will utilise a medication library to infuse their drugs, if appropriate.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_Published
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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 Investigate developing limits for entries in the Cerner infusion chart for selected narrow-dose-safety-profile drugs.
Verbatim wording from the response “The issue raised refers to the current situation where a user can input a value for a drug infusion rate into the iView infusion section of the Cerner clinical system chart without any limits. This was identified as a contributing factor in the drug dosing error associated with Mr Hussain’s care.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_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 Include automated drug prescription-to-administration specifications in the future single clinical system procurement.
Verbatim wording from the response “The Trust accepts the need to strengthen the decision support tools within the current clinical systems. We are looking to further improve the embedded system rules regarding drug prescription and administration.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_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 Devise and document an escalation process, standard operating procedure and quick-reference flowsheet for exceptional medication-library overrides.
Verbatim wording from the response “However, in some exceptional circumstances outside the norm, it may be necessary for patient care to deviate from the specified dosing limits and therefore the infusion pumps offer the capability to infuse medication outside of the library where safety limits are not imposed. Staff will be educated that they must not work outside of the medication library unless in exceptional circumstances and an escalation process will be devised to enable a clear audit trail of all communication and decisions made between staff members which will be documented in the patients’ medical notes. This will be detailed in a standard operating procedure and will contain a flowsheet of the escalation process as a quick reference guide for staff members. A working group has been set up on NICU, who already use a medication library, to trial this.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_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 Introduce new infusion pumps across all sites with bi-directional communication capability between pumps and the Cerner clinical system.
Verbatim wording from the response “In addition, the Trust is in the process of introducing new infusion pumps across all sites. One of the requirements for the procurement of these pumps was that they should allow bi-directional communication between the pumps and the Cerner clinical system. This would allow auto-programming of the pump from the electronic prescription and would automatically update the hourly infusion rate recorded in the iView infusion section of the drug chart. If the bi-directional communication capability of these pumps were to be used, this would significantly reduce the volume of manually entered data and remove the risk of transcription errors by bedside nurses when programming pumps or recording infusion rates.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a working group to trial medication-library use on the neurosciences intensive care unit.
Verbatim wording from the response “However, in some exceptional circumstances outside the norm, it may be necessary for patient care to deviate from the specified dosing limits and therefore the infusion pumps offer the capability to infuse medication outside of the library where safety limits are not imposed. Staff will be educated that they must not work outside of the medication library unless in exceptional circumstances and an escalation process will be devised to enable a clear audit trail of all communication and decisions made between staff members which will be documented in the patients’ medical notes. This will be detailed in a standard operating procedure and will contain a flowsheet of the escalation process as a quick reference guide for staff members. A working group has been set up on NICU, who already use a medication library, to trial this.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_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 Trial medication-library use through the neurosciences intensive care unit working group.
Verbatim wording from the response “However, in some exceptional circumstances outside the norm, it may be necessary for patient care to deviate from the specified dosing limits and therefore the infusion pumps offer the capability to infuse medication outside of the library where safety limits are not imposed. Staff will be educated that they must not work outside of the medication library unless in exceptional circumstances and an escalation process will be devised to enable a clear audit trail of all communication and decisions made between staff members which will be documented in the patients’ medical notes. This will be detailed in a standard operating procedure and will contain a flowsheet of the escalation process as a quick reference guide for staff members. A working group has been set up on NICU, who already use a medication library, to trial this.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_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 A complete closed-loop drug administration solution cannot be implemented until clinical systems are rationalised into a single system.
Verbatim wording from the response “The Trust acknowledges there are multiple clinical systems making up the electronic patient record in the organisation. We accept the need to rationalise the number of clinical systems in use across our critical care units. This is likely to take at least two years to consider and implement.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_Published
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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 Matching prescriptions to constantly adjusted infusion rates is impractical in critical care because bedside rates frequently change.
Verbatim wording from the response “4. Adopting a system of flagging up where prescription and administration of drugs is different.” Source location 2021-0399-Response-from-Oxford-University-Hospitals_Published
Open published response
12 Feb 2021 Mrs Anne Patricia Harper · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2 Lack of a major trauma lead consultant View source Lack of a trauma co-ordinator View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Anne Patricia Harper · 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 Anne Patricia Harper, aged 78, fell down the stairs at home on 13 September 2020, sustained extensive fractures, developed respiratory failure and died in hospital on 14 September 2020. The report identified concerns about the absence of trauma leadership and coordination, delays in assessment and transfer, gaps in monitoring and analgesia, and the lack of an adequate alternative analgesia plan.
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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a major trauma lead consultant
Wider context from the report “1. I heard evidence that a Major Trauma Centre is expected to have a major trauma lead consultant , and a trauma co-ordinator (in accordance with NICE guidelines). I understand that the Trust does not have these posts and that this has been the position since at least 2018.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a trauma co-ordinator
Wider context from the report “1. I heard evidence that a Major Trauma Centre is expected to have a major trauma lead consultant, and a trauma co-ordinator (in accordance with NICE guidelines). I understand that the Trust does not have these posts and that this has been the position since at least 2018.
” 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 Redefine Orthopaedic Trauma Consultant posts as Major Trauma Consultant roles.
Verbatim wording from the response “The requirement for all major trauma patients to be initially managed by a single group of consultants has been difficult to implement because of the established successful model of care as described above. This work has been ongoing since the last ‘in person’ peer review in 2018. We will redefine the current Orthopaedic Trauma consultants to that of the 'MTC Consultant'.” Source location 2021-0174-Response-from-Oxford-University-Hospitals-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relocate trauma services to adjacent clinical areas to support overall care under a Major Trauma Consultant.
Verbatim wording from the response “As the Trust moves to recover from the Covid-19 pandemic, we will relocate trauma services to clinical areas that are physically adjacent. With this in place, patients would be admitted under the overall care of a ‘Major Trauma Consultant’ who will be an Orthopaedics consultant. If their trauma is exclusively related to a different surgical speciality, referral would be made to that speciality for ongoing lead care. If the patient has orthopaedic/multiple (poly) trauma the patient would remain under the care of the MTC Consultant. Isolated traumatic brain injuries will continue to be admitted under the care of neurosurgery. We would expect to retain some flexibility if a patient-specific factor required variation to this plan in order to ensure best care for the patient.” Source location 2021-0174-Response-from-Oxford-University-Hospitals-Redacted
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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 arrangements ensure all major trauma patients have a lead consultant with expertise to manage their injuries.
Verbatim wording from the response “the hospital trauma service and leads the multidisciplinary team care. At the OUH there is a Trauma Orthopaedic Consultant available 24 hours a day. That consultant can lead on the involvement of any other staff required.” Source location 2021-0174-Response-from-Oxford-University-Hospitals-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reported concerns could not have changed the outcome of Mrs Harper’s case.
Verbatim wording from the response “As you described in your report, I do not feel that either of the reported concerns could have changed the sad outcome of Mrs Harper’s case however we are committed to delivering change for future patients.” Source location 2021-0174-Response-from-Oxford-University-Hospitals-Redacted
Open published response
15 Dec 2020 Don Maximus Del Rocco Fernandes · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1 Failure of NGT placement policy changes to provide clear guidance on when x-ray confirmation is required 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
Don Maximus Del Rocco Fernandes · 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
Don Maximus Del Rocco Fernandes, a three-month-old infant with VACTERL Association, died after a nasogastric tube was dislodged, replaced, and flushed; the tube had been inserted into the left main bronchus. The principal concerns were the failure to correctly confirm tube placement, uncertainty arising from a change in x-ray policy, and whether further measures were needed to prevent similar incidents involving misplaced tubes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of NGT placement policy changes to provide clear guidance on when x-ray confirmation is required
Wider context from the report “In this case an x-ray would be needed to confirm placement. It appears that the nurse in question was concerned about the number of x-rays and was made aware about the change to policy for Don Maximus but it appears that she misunderstood it and did not believe an x-ray was required in this case .
There are two points that arise, firstly, there is the dilemma in terms of the need to correctly confirm the NGT position but also the need to avoid excess radiation. I enquire if there is any method of reliably confirming the place of the NGT? I assume not as otherwise it would be routine. I understood from information provided at inquest that there are no cameras small enough that can be used to confirm the position.
The second point is the fact that the change to normal policy in Don Maximus case, whilst understandable and perhaps necessary, introduced an element of uncertainty particularly with regard to a nurse caring for Don Maximus for the first time as was the case here. I enquire if there are any additional measures to reduce the prospect of a similar incident occurring in future.
” 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 Complete the specific RCA Action Plan actions for nasogastric-tube policy and staff competence.
Verbatim wording from the response “1. With reference to the RCA Report at appendix 1: Action Plan, there are a number of recommendations concerning the policy for the insertion and use of NG tubes in infants and a recommendation that the nurse involved be reassessed for NGT competence. It appears that the action points were due for completion at the end of 2019 and beginning of 2020. In particular, I have seen the more user friendly policy and the ‘at a glance’ appendix that now forms part of the policy.” Source location 2021-0172-Response-from-Oxford-University-Hospitals-Redacted
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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 policy, handover, and completed action-plan measures were considered sufficient, so no additional safety measures were required.
Verbatim wording from the response “c. I do not accept that this created an uncertainty. The role of the handover (as happened on this occasion) is to identify an individual child’s specific care needs. This system was in place in respect of Don Maximus’ care. I can confirm that the specific actions identified from the RCA Action Plan were completed and I am therefore satisfied that all” Source location 2021-0172-Response-from-Oxford-University-Hospitals-Redacted
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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 disputes that caring for this patient involved a change from normal policy or created uncertainty about when an X-ray was required.
Verbatim wording from the response “a. For all patients (whether children or adults), the gold standard for confirming placement of an NG tube is an x-ray. This is because other tests (such as aspiration of the tube) may produce inaccurate results. Accurate confirmation can only be obtained by way of an x-ray. All clinical staff are acutely aware of the implication that too many x-rays can have on an individual patient. It is a difficult balancing exercise to avoid excessive radiation, but the only truly reliable method of confirming NG tube placement is from an X-ray.” Source location 2021-0172-Response-from-Oxford-University-Hospitals-Redacted
Open published response
17 Sep 2018 Marian Grant · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Failure to ensure staff act upon VTE prophylaxis alerts View source Failure to ensure VTE prophylaxis for trauma patients outlying on non-trauma wards View source Failure of EPR VTE alerts to appear when records remain open 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
Marian Grant · 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
Marian Grant, aged 74, tripped and fell on 14 April 2018 and died from a pulmonary embolism during surgery for a fractured neck of femur on 16 April 2018. The principal concerns were the omission of VTE prophylaxis, particularly for patients placed on non-trauma wards, and the failure of EPR alerts and other checks to ensure that prophylaxis was prescribed and acted upon.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff act upon VTE prophylaxis alerts
Wider context from the report “2. The second concern relates to ignoring the VTE prophylaxis alerts on EPR. I note from the RCA Report that the warning was visible on exiting the record by all staff. ████████ explained however that often the warning would not be seen because sometimes a doctor does not actually exit the record but keeps it open (albeit secure). It is surprising that from the time of transfer to the neuro-science ward from ED until the time when the patient was seen by the Consultant Anaesthetist ████████ on the morning of surgery on 16 April that the EPR was accessed 27 times by staff members and yet none of the staff interviewed recalled seeing the alert. A system designed with fail-safes in the form of alerts is obviously not effective if the alerts are not seen or routinely ignored . Recommendation 8 on the Action Plan refers to this issue and I see that an email has been sent out to the EPR Lead and that a new version of EPR will prevent staff being able to exit the EPR record until VTE alerts have been dealt with. As mentioned, it seems though that doctors do not always exit the record and, as I understand it, the alert will not pop up unless the record is being exited. It would be appreciated if you could provide some clarification on this and also address the wider issue of alerts not being acted upon .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure VTE prophylaxis for trauma patients outlying on non-trauma wards
Wider context from the report “1. The first concern relates to what are referred to as ‘outlying patients’. Mrs Grant went from the emergency department to a neuro-science ward because there were no beds on a trauma ward. It appears that her placement on a ward other than a trauma ward raised issues in respect of her care and, in particular, it meant she was not being cared for by trauma nurses who might ordinarily be expected to pick up the omission concerning VTE prophylaxis.
I understand it is relatively common for a trauma patient to be placed on a ward other than a trauma ward. I understand that this may be unavoidable but I am concerned about there being sufficient safeguards in place . I see from the Action Plan that recommendations 1 and 7 refer to this issue. There has been an audit and the trauma co-ordinator is to check VTE prophylaxis has been prescribed to trauma patients outlying on non-trauma wards. I seek reassurance that the audit of care for such patients confirms that the same standard of care is delivered regardless of location . I also seek information and reassurance about the practical steps taken by the trauma co-ordinator to check VTE prophylaxis . There were a number of system checks which failed in this case and it is therefore important that system checks are effective .
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of EPR VTE alerts to appear when records remain open
Wider context from the report “2. The second concern relates to ignoring the VTE prophylaxis alerts on EPR. I note from the RCA Report that the warning was visible on exiting the record by all staff. ████████ explained however that often the warning would not be seen because sometimes a doctor does not actually exit the record but keeps it open (albeit secure). It is surprising that from the time of transfer to the neuro-science ward from ED until the time when the patient was seen by the Consultant Anaesthetist ████████ on the morning of surgery on 16 April that the EPR was accessed 27 times by staff members and yet none of the staff interviewed recalled seeing the alert. A system designed with fail-safes in the form of alerts is obviously not effective if the alerts are not seen or routinely ignored. Recommendation 8 on the Action Plan refers to this issue and I see that an email has been sent out to the EPR Lead and that a new version of EPR will prevent staff being able to exit the EPR record until VTE alerts have been dealt with. As mentioned, it seems though that doctors do not always exit the record and, as I understand it, the alert will not pop up unless the record is being exited . It would be appreciated if you could provide some clarification on this and also address the wider issue of alerts not being acted upon.
” 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 Audit trauma patients across the Trust to benchmark VTE prophylaxis care and identify discrepancies.
Verbatim wording from the response “To put the Trust’s response in context, and in advance of the Inquest heard on 5 September 2018, the Trust had already put in place a number of steps to address the concerns raised above. This included an audit undertaken by the Clinical and Governance Lead for Trauma at the end of August to benchmark the standard of care provided across the Trust for trauma patients. I readily acknowledge that the audit results confirmed there were discrepancies across the Trust in the management and administration of VTE prophylaxis.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check daily at multidisciplinary meetings that reviews of outlying trauma patients are taking place.
Verbatim wording from the response “In addition to the steps above, the Matron for the trauma team also checks, at the daily multi-disciplinary meetings that, the reviews described above are actually taking place. Her perception of the new systems is that it is working well.” Source location Marion-Grant-Response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand personal electronic worklists to individual doctors and introduce nursing worklists for outstanding VTE prophylaxis tasks.
Verbatim wording from the response “The IT team are also seeking to expand upon the personal electronic work lists currently used by the pharmacists so that personal work lists can be created for each individual doctor in the Trust.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the effectiveness of the mandatory VTE electronic patient record alert system.
Verbatim wording from the response “An audit of the efficacy of this new system is due to be undertaken in January 2019. Again, I would be happy to share with you the outcome of the audit if this would be of interest to your office.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue consultant checks that VTE assessments and prescriptions are completed for all new trauma patients, regardless of location.
Verbatim wording from the response “The Matron for the trauma department was also able to confirm that she regularly observes that the trauma team consultant surgeons also check that VTE assessments and prescriptions are being carried out on all new patients regardless of where they are based.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake the deferred follow-up audit of outlying trauma patients and publish its results to assess equality of VTE prophylaxis care.
Verbatim wording from the response “At around the time that your report was issued, the audit undertaken in August 2018 was reviewed to check that outliers were receiving VTE prophylaxis as they would on the trauma wards and a decision made to defer the next audit (which was due to be undertaken in September 2018) until December 2018. The reason that the planned follow up audit has been deferred is two-fold.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review outlying trauma patients daily to verify that appropriate VTE prophylaxis is prescribed, using senior trauma nursing cover when required.
Verbatim wording from the response “Further, the Clinical Nurse Specialist had already been tasked to review outlying patients on a daily basis to check that appropriate VTE prophylaxis is being prescribed to all relevant patients who are not based on the trauma wards, prior to the Inquest itself.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require doctors to address the VTE alert before exiting or navigating away from the electronic patient record.
Verbatim wording from the response “As a direct result of the death of Mrs Grant and a few days prior to the Inquest, the Trust launched a new system which meant that doctors are unable to exit the EPR until the VTE alert has been dealt with (a hard pop up alert). In practice, this means that the alert confirming that prescription of VTE prophylaxis is required, cannot be overridden until the drug has actually” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deploy an electronic whiteboard displaying outstanding patient tasks and VTE prophylaxis status using traffic-light indicators.
Verbatim wording from the response “Other IT developments in the pipeline include the development and deployment of an electronic ‘white board’ for use by authorised users (for example a ward manager) and ward staff so instant access can be ascertained with regard to the relevant cohort of patients to check what outstanding tasks remain outstanding for each patient. This framework will also be deployed for individual clinician worklists as described below.” Source location Marion-Grant-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Streamline electronic alerts by moving soft alerts into the record sidebar and limiting hard pop-ups to key safety issues.
Verbatim wording from the response “Recognising the importance of VTE prophylaxis and also taking into account operator “alert fatigue” the Trust are in the process of streamlining and adapting the way in which alerts are brought to the attention of clinical staff.” Source location Marion-Grant-Response
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 follow-up audit was deferred because variable outlier numbers required a sufficient patient sample to produce a meaningful assessment.
Verbatim wording from the response “At around the time that your report was issued, the audit undertaken in August 2018 was reviewed to check that outliers were receiving VTE prophylaxis as they would on the trauma wards and a decision made to defer the next audit (which was due to be undertaken in September 2018) until December 2018. The reason that the planned follow up audit has been deferred is two-fold.” Source location Marion-Grant-Response
Open published response
31 Oct 2016 James Francis Flynn · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Lack of detailed care plans for patient discharge View source Failure to inform immediate family of patient discharge View source Failure to ensure food or essential provisions are available after discharge for patients with diabetes 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
James Francis Flynn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Francis Flynn, who had chronic pancreatitis, was discharged home late on 8 December 2015 and was found unresponsive at home the following day; death was confirmed at 18:06. Concerns included discharge while he remained very unwell without a detailed care plan, with his immediate family unaware and no food or provisions available despite his type 2 diabetes, and that inadequate discharge planning and management could put patients’ lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed care plans for patient discharge
Wider context from the report “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place . His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic.
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform immediate family of patient discharge
Wider context from the report “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic.
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
” 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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure food or essential provisions are available after discharge for patients with diabetes
Wider context from the report “(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place. His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic .
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
” Open source report
3 Feb 2014 Scarlett Lucie SINCLAIR · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to adequately assess babies' wellness, stability and suitability before transfer between neonatal units 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
Scarlett Lucie SINCLAIR · 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
Scarlett Lucie SINCLAIR was born at 28 weeks gestation and transferred to Southmead Hospital’s neonatal unit at 23 days old. Within hours she became unwell, developed a distended abdomen and acute deterioration, and died a few hours after transfer for surgical management of extensive necrosis. The substantive concern was whether the assessment of a baby’s wellness, stability and suitability was sufficient before transfer between neonatal units.
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 Oxford University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess babies' wellness, stability and suitability before transfer between neonatal units
Wider context from the report “During the inquest evidence was given from the Consultant Locum Neonatologist at Oxford as to how a baby is assessed as being suitable for transfer to another neonatal unit. I also heard evidence from a Consultant Neonatologist from Bristol who confirmed that the assessment of suitability for transfer from the United Hospitals Bristol NHS Foundation Trust means that a baby is not transferred to another neonatal unit until they are in a much more stable condition.
I would therefore ask that you review your policy for assessing a babies wellness, stability and indeed suitability prior to approving that baby fit for transfer between neonatal units
” 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