21 Jun 2019 Deborah Anne Hopkinson · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Failure of the computer system to support timely specialist involvement View source Lack of specialist knowledge to recognise the association between Cushing’s disease and PJP View source Unavailability of the CT scanner for abdominal imaging View source Failure of the PACS system to provide access to MRI scans View source Delays in obtaining specialist-centre advice despite lack of local expertise View source Unavailability of the cortisol sample analyser View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Deborah Anne Hopkinson · 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
Deborah Anne Hopkinson was treated for Cushing’s disease caused by a pituitary adenoma and later developed pneumocystis pneumonia. Her condition deteriorated during intensive care, and she died at Fairfield General Hospital on 26 September 2018 after a cardiac arrest. Concerns included equipment failures, delays in specialist advice and delays in recognising and treating complications associated with Cushing’s disease.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the computer system to support timely specialist involvement
Wider context from the report “1. The inquiry heard that there were numerous occasions when equipment failure occurred and this is likely to have had some impact on the treatment which the deceased received
i. When the deceased was re-admitted to hospital on 12 September 2018 there was delay of some 6 days in involving the endocrine consultant at Fairfield Hospital and the reason given during the inquiry was that the computer system was down .
ii. The inquiry heard the importance about controlling the cortisol levels yet there was evidence to the effect that the analyser for running the cortisol sample was down multiple times during the deceased’s admission.
iii. There was a significant deterioration in the deceased’s condition in the evening of 25 September 2018 but a CT abdomen could not be performed because the CT scanner at Fairfield Hospital was not working.
iv. When the deceased’s was discussed at an MDT meeting on 13 September 2018 the MRI scan could not be viewed on the PACS 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist knowledge to recognise the association between Cushing’s disease and PJP
Wider context from the report “2. There was delay in obtaining advice from a specialist centre such as Salford Royal Hospital or the Christie Hospital despite a lack of expertise at Fairfield General Hospital as evidenced by the following:
i. ████████ Consultant Endocrinologist at Salford Royal Hospital explained to the deceased’s husband ████████ and her sister ████████ that she was not a specialist in Cushing’s disease when discussing the deceased’s case on 17 September 2018.
ii. In the Investigation Report the Trust accepted that there had been a delay in treatment for probable PJP because the medical team did not recognise the association between Cushing’s disease and PJP due to lack of specialist knowledge .
On 21 August 2018 an MRI pituitary revealed a pituitary adenoma which was the most likely cause of the deceased’s Cushing disease yet it was not until 28 August 2018 that ████████ Consultant Endocrinologist at Salford Royal Hospital was contacted.
Prior to the deceased’s re-admission to hospital on 12 September 2018 she contracted pneumocystis pneumonia, a recognised complication of Cushing’s disease. There was delay in obtaining advice from a specialist centre despite a significant deterioration in her condition and when there was involvement from a Consultant Endocrinologist at the Christie Hospital this was only achieved because of the intervention of the deceased’s sister.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the CT scanner for abdominal imaging
Wider context from the report “1. The inquiry heard that there were numerous occasions when equipment failure occurred and this is likely to have had some impact on the treatment which the deceased received
i. When the deceased was re-admitted to hospital on 12 September 2018 there was delay of some 6 days in involving the endocrine consultant at Fairfield Hospital and the reason given during the inquiry was that the computer system was down.
ii. The inquiry heard the importance about controlling the cortisol levels yet there was evidence to the effect that the analyser for running the cortisol sample was down multiple times during the deceased’s admission.
iii. There was a significant deterioration in the deceased’s condition in the evening of 25 September 2018 but a CT abdomen could not be performed because the CT scanner at Fairfield Hospital was not working .
iv. When the deceased’s was discussed at an MDT meeting on 13 September 2018 the MRI scan could not be viewed on the PACS 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the PACS system to provide access to MRI scans
Wider context from the report “1. The inquiry heard that there were numerous occasions when equipment failure occurred and this is likely to have had some impact on the treatment which the deceased received
i. When the deceased was re-admitted to hospital on 12 September 2018 there was delay of some 6 days in involving the endocrine consultant at Fairfield Hospital and the reason given during the inquiry was that the computer system was down.
ii. The inquiry heard the importance about controlling the cortisol levels yet there was evidence to the effect that the analyser for running the cortisol sample was down multiple times during the deceased’s admission.
iii. There was a significant deterioration in the deceased’s condition in the evening of 25 September 2018 but a CT abdomen could not be performed because the CT scanner at Fairfield Hospital was not working.
iv. When the deceased’s was discussed at an MDT meeting on 13 September 2018 the MRI scan could not be viewed on the PACS 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining specialist-centre advice despite lack of local expertise
Wider context from the report “2. There was delay in obtaining advice from a specialist centre such as Salford Royal Hospital or the Christie Hospital despite a lack of expertise at Fairfield General Hospital as evidenced by the following:
i. ████████ Consultant Endocrinologist at Salford Royal Hospital explained to the deceased’s husband ████████ and her sister ████████ that she was not a specialist in Cushing’s disease when discussing the deceased’s case on 17 September 2018.
ii. In the Investigation Report the Trust accepted that there had been a delay in treatment for probable PJP because the medical team did not recognise the association between Cushing’s disease and PJP due to lack of specialist knowledge.
On 21 August 2018 an MRI pituitary revealed a pituitary adenoma which was the most likely cause of the deceased’s Cushing disease yet it was not until 28 August 2018 that ████████ Consultant Endocrinologist at Salford Royal Hospital was contacted.
Prior to the deceased’s re-admission to hospital on 12 September 2018 she contracted pneumocystis pneumonia, a recognised complication of Cushing’s disease. There was delay in obtaining advice from a specialist centre despite a significant deterioration in her condition and when there was involvement from a Consultant Endocrinologist at the Christie Hospital this was only achieved because of the intervention of the deceased’s sister.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the cortisol sample analyser
Wider context from the report “1. The inquiry heard that there were numerous occasions when equipment failure occurred and this is likely to have had some impact on the treatment which the deceased received
i. When the deceased was re-admitted to hospital on 12 September 2018 there was delay of some 6 days in involving the endocrine consultant at Fairfield Hospital and the reason given during the inquiry was that the computer system was down.
ii. The inquiry heard the importance about controlling the cortisol levels yet there was evidence to the effect that the analyser for running the cortisol sample was down multiple times during the deceased’s admission.
iii. There was a significant deterioration in the deceased’s condition in the evening of 25 September 2018 but a CT abdomen could not be performed because the CT scanner at Fairfield Hospital was not working.
iv. When the deceased’s was discussed at an MDT meeting on 13 September 2018 the MRI scan could not be viewed on the PACS system.
” Open source report
29 Mar 2019 Ann Corfield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 5 Delays in prescribing prophylactic anticoagulation for patients at high risk of VTE View source Lack of staff training to administer intravenous fluids in the psychiatric unit View source Failure to provide written handovers containing medication information during patient transfers View source Failure to administer prescribed prophylactic anticoagulation View source Failure to complete fluid balance charts accurately and consistently View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ann Corfield · 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
Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in prescribing prophylactic anticoagulation for patients at high risk of VTE
Wider context from the report “1. I heard evidence that although Mrs Corfield was at high risk of developing a VTE, following her admission to Park House on 28th June, prophylactic anticoagulation was not prescribed for her until 30th June when a prescription for clexane (enoxaparin) was issued. Further, although clexane was prescribed, it was never administered to Mrs Corfield.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training to administer intravenous fluids in the psychiatric unit
Wider context from the report “2. Further, I also heard evidence that the staff at Park House were not trained to administer intravenous fluids . This meant that Mrs Corfield had to be transferred to a North Manchester Hospital for intravenous fluids when she was in urgent need of specialist psychiatric care and treatment. I formed the view that ████████ was left extremely frustrated that he was unable to treat Mrs Corfield with intravenous fluids whilst she was a patient at Park House.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written handovers containing medication information during patient transfers
Wider context from the report “1. I heard evidence at the Inquest staff at Park House were not aware that Mrs Corfield was receiving an anticoagulant in the form of enoxaparin whilst she was a patient at Royal Oldham Hospital to reduce the risk of her developing a VTE or that she had refused this medication whilst a patient ROH . I received written evidence from ████████ that the Pennine Acute Trust has in place an Adult Transfer Policy and a Form should be generated which includes details with regards the patient’s medication and most recent observations. However, the evidence I heard from ████████, Consultant Psychiatrist at Park House, was that this unit still does not receive a written handover .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed prophylactic anticoagulation
Wider context from the report “1. I heard evidence that although Mrs Corfield was at high risk of developing a VTE, following her admission to Park House on 28th June, prophylactic anticoagulation was not prescribed for her until 30th June when a prescription for clexane (enoxaparin) was issued. Further, although clexane was prescribed, it was never administered to Mrs Corfield .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fluid balance charts accurately and consistently
Wider context from the report “2. Dehydration clearly played a part in Mrs Corfield’s death. I heard evidence at Inquest that Fluid Balance Charts were poorly completed indeed some of them were not completed at all or contained errors with simple arithmetic . At the Inquest, I heard conflicting evidence about the usefulness of fluid balance charts. Witnesses who were employed by Pennine Acute Trust tended to place more reliance on the results of blood tests. However, ████████ emphasised to me the importance of FBC charts in a patient like Mrs Corfield who had a history of chronic kidney disease because blood tests were an ‘insensitive measure’ of hydration. I received helpful written evidence from ████████ who is the Divisional Director of Nursing for Medicine at Royal Oldham Hospital, dated 31st January 2019, which, at paragraph 17, shows there are still ongoing problems with the way fluid balance charts are completed some two and a half years after Mrs Corfield’s death.
” Open source report
19 Mar 2019 Graham Tailby · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of intraosseous drills on crash trolleys 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
Graham Tailby · 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
Graham Tailby, a patient detained under the Mental Health Act and receiving care on Juniper Ward, was found unresponsive in his room on 22 December 2015 and died despite resuscitation efforts. The inquest found bronconeumonia and combined sertraline and fentanyl toxicity, but it was unclear how the toxicity occurred or developed. A concern was raised that intraosseous drills were not available on crash trolleys, potentially limiting emergency intervention options.
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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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of intraosseous drills on crash trolleys
Wider context from the report “His evidence was that he whilst struggling to gain intravenous access to administer relevant drugs to Mr Tailby he had considered the possible use and assistance of a piece of equipment known as an intraosseous drill. The equipment however wasn’t present on the crash trolley which had been brought to Mr Tailby’s room.
In the event he was in fact able to secure intravenous access and proceed accordingly. He also acknowledged that whilst the use of an intraosseous drill was an option with which he was familiar, that might not be the case for others and in any event is not a core requirement of expertise of those involved in emergency responses such as that which took place.
The point that I raise is that the provision of the intraosseous drill on crash trolleys may provide another route of intervention for those familiar and trained in its use in other circumstances in the future, and having that option may prevent deaths in the context of emergency crash responses to wards for which the Trust has responsibility.
” Open source report
12 Mar 2019 Marjorie GARTSIDE · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 5 Failure to provide accurate mobility information during hospital-to-home communication View source Failure to send prescribed anticipatory medication with the person at discharge View source Lack of clarity about palliative-care status at discharge View source Failure to hand over care View source Discharge processes lacking robustness View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Marjorie GARTSIDE · 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
Marjorie Gartside, aged 100, fractured her hip in an unwitnessed fall at a residential home and underwent surgery. She was discharged from hospital on two occasions, with concerns about inaccurate information regarding her mobility, unsafe discharge processes, lack of care handover and unclear palliative-care arrangements, and anticipatory medication not being sent with her. She died at the Home on 19 October 2018.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate mobility information during hospital-to-home communication
Wider context from the report “1. That the information provided by the Royal Oldham Hospital to the Home on 10 October 2018 was inaccurate in suggesting that Mrs Gartside was able to mobilise . Had that information been relied upon by the Home it would have resulted in Mrs Gartside not having suitable or appropriate equipment in place for her return.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to send prescribed anticipatory medication with the person at discharge
Wider context from the report “4. That the prescribed anticipatory medication was not sent with Mrs Gartside when she was discharged on 17 October 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about palliative-care status at discharge
Wider context from the report “3. There appears to have been no handover of care and a lack of clarity as to whether Mrs Gartside was for palliative care when she was discharged from the Royal Oldham Hospital on 12 October 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over care
Wider context from the report “3. There appears to have been no handover of care and a lack of clarity as to whether Mrs Gartside was for palliative care when she was discharged from the Royal Oldham Hospital on 12 October 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge processes lacking robustness
Wider context from the report “2. That Mrs Gartside’s discharge from the Royal Oldham Hospital on 12 October 2018 appears to have been unsafe and raises a concern about the robustness of discharge processes .
” Open source report
28 Nov 2018 John Lea · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Failure to update and complete critical risk assessments View source Insufficient progress in the ward's NAAS rating View source Failure to escalate when an on-call doctor does not attend after a marked change in oxygen saturations View source Gaps in clinical documentation and record keeping View source Incorrect calculation of NEWS scores View source Poor communication within the nursing team about bay tagging View source Failure to adhere to patient observation policy and protocol View source Failure to adhere to falls prevention policy and protocol View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Lea · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Lea was admitted to hospital for management of heart failure and was later found collapsed on the ward after the bay-tagging nurse temporarily left without arranging monitoring. Resuscitation was unsuccessful and his death was confirmed on 12 June 2017; the report considered a sudden cardiac-related event more likely than not. Concerns included incomplete risk assessments, poor communication, gaps in documentation, failure to escalate a change in oxygen saturations, incorrectly calculated NEWS scores, and failures to follow relevant policies and protocols.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update and complete critical risk assessments
Wider context from the report “1. In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient progress in the ward's NAAS rating
Wider context from the report “7. Insufficient progress with regard to the NAAS rating for the ward in question (initial assessment a year ago ‘red’, more recent assessment ‘high amber’ ).
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate when an on-call doctor does not attend after a marked change in oxygen saturations
Wider context from the report “4. No escalation when the on call doctor failed to attend following a marked change in the deceased’s oxygen saturations .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Gaps in clinical documentation and record keeping
Wider context from the report “3. Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased ).
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect calculation of NEWS scores
Wider context from the report “5. Incorrectly calculated NEWS scores . The NEWS was designed to address mistakes brought about by the previous early waring score tool (EWS), yet mistakes with regard to score calculations continue .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication within the nursing team about bay tagging
Wider context from the report “2. Poor communication between the nursing team , with particular reference to ‘bay tagging’ .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to patient observation policy and protocol
Wider context from the report “6. Failure to adhere to Trust policy/protocol – prevention of falls, patient observation .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to falls prevention policy and protocol
Wider context from the report “6. Failure to adhere to Trust policy/protocol – prevention of falls , patient observation.
” Open source report
25 Jul 2018 Paul Robert Allan · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Failure to consult or work with drug and alcohol advisory services View source Failure to transfer people between community mental health teams when they move 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
Paul Robert Allan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 July 2017, Paul Robert Allan walked onto the track at Oxford Circus tube station and was struck by a westbound train. Concerns included his discharge from the Rochdale Community Mental Health Team without transfer to the corresponding team in Stoke, and a failure to consult or work with drug and alcohol advisory services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult or work with drug and alcohol advisory services
Wider context from the report “2) The Rochdale community Mental Health Team failed to consult or work with the Drug and Alcohol advisory services in relation to Paul Robert Allan as it is required to do.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer people between community mental health teams when they move
Wider context from the report “1) The Rochdale Community Mental Health Team discharged Paul Robert Allan from their care instead of transferring him to the Community Mental Health Team in Stoke where Paul Robert Allan was moving to.
” Open source report
21 Mar 2018 Barbara Johnson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to consider ECG machine printouts in clinical interpretation and judgment 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
Barbara Johnson · 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
Barbara Johnson was detained under Section 3 of the Mental Health Act and admitted to the Moorside Unit on 19 April 2017. She suffered a heart attack on 30 April 2017 and was pronounced deceased after resuscitation efforts. The principal concerns included gaps in physical observations and clinical review, deficiencies in handover and emergency-response equipment, and junior doctors’ failure to consider ECG machine printout abnormalities during interpretation.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider ECG machine printouts in clinical interpretation and judgment
Wider context from the report “It is understood that Pennine Acute NHS Trust employed the junior doctors on the Moorside Unit at Tameside General Hospital. During the course of the inquest we heard evidence from ████████ regarding ECGs that he carried out on Barbara Johnson on the 19th April 2017 at the time of her admission to the Moorside Unit. A number of the doctors understandably did not recall carrying out the ECGs but formed the view from the records that the patient was moving at the time that the ECGs were performed. Thus, he explained, had an impact on the ECG although he was not able to explain the precise impact. At the top of 2 of the ECGs there was a printout from the machine which stated (inter alia) “T Wave abnormality”, “Possible anterolateral ischemia” and “abnormal ECG”. ████████ evidence was that regard would not be had to the printout summary at the top of the ECG and that the doctor would interpret the ECG himself. Whilst it was accepted that the printout is no substitute for a doctor’s interpretation, it did give cause for concern that junior doctors employed by the Trust were routinely ignoring the printout . It was of concern that the printout was not being considered and/or was not informing clinical interpretation and judgment .
” Open source report
14 Mar 2018 Janet Hall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to accurately transcribe significant individual results into discharge letters View source Failure to include a complete set of blood results in discharge letters 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
Janet Hall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Hall died after a series of hospital admissions and attendances, with the medical cause described as acute left ventricular failure and B Cell lymphoma on a background of ischaemic heart disease. A principal concern was that an Emergency Department discharge letter stated that blood tests were normal, although her full blood count was abnormal, and that discharge letters did not routinely include complete blood results, limiting opportunities for GPs to identify trends.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately transcribe significant individual results into discharge letters
Wider context from the report “Following Mrs Hall’s attendance at the Royal Oldham Emergency Department, a letter was written to her GP which included the text ‘Bloods and ECG all normal’. The evidence before the court was that contrary to this statement, Mrs Hall’s full blood count was, in fact, abnormal, with a slightly low haemoglobin at 96 grams / litre.
████████ Consultant in Emergency Medicine, explained in his evidence that in contrast to other systems which operate across the Trust whereby complete sets of results are automatically incorporated into discharge letters, the Emergency Department system is currently predicated on junior doctors accurately transcribing significant individual results .
In addition to increasing the chances for errors of the sort that occurred in this case , it is a matter of concern that the absence of a complete set of blood results in discharge letters reduces the potential for GPs to compare results with others on their own systems, reducing the opportunity for trend analysis.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include a complete set of blood results in discharge letters
Wider context from the report “Following Mrs Hall’s attendance at the Royal Oldham Emergency Department, a letter was written to her GP which included the text ‘Bloods and ECG all normal’. The evidence before the court was that contrary to this statement, Mrs Hall’s full blood count was, in fact, abnormal, with a slightly low haemoglobin at 96 grams / litre.
████████ Consultant in Emergency Medicine, explained in his evidence that in contrast to other systems which operate across the Trust whereby complete sets of results are automatically incorporated into discharge letters, the Emergency Department system is currently predicated on junior doctors accurately transcribing significant individual results.
In addition to increasing the chances for errors of the sort that occurred in this case, it is a matter of concern that the absence of a complete set of blood results in discharge letters reduces the potential for GPs to compare results with others on their own systems, reducing the opportunity for trend analysis.
” Open source report
28 Sep 2017 Pauline Hayston · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment View source Unsuitability of wireless WiFi activation when several fall mats are in proximity View source Unreliability of Rambledguard fall mats for their intended purpose 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
Pauline Hayston · 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
Pauline Hayston, who had reduced mobility, frailty and recent falls, sustained an unwitnessed fall while attempting to mobilise as an inpatient and later died following a fractured neck of femur and resulting immobility. The concerns identified related to the reliability and fitness for purpose of the Rambledguard falls mats, the suitability of the wireless system when several mats were in use, and the absence of technical instructions for nursing staff about operational 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of wireless WiFi activation when several fall mats are in proximity
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Rambledguard fall mats for their intended purpose
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” Open source report
5 Jul 2017 Patricia Norfolk · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Lack of daily senior clinician reviews for patients 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
Patricia Norfolk · 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
Patricia Norfolk was admitted to Royal Oldham Hospital after discovery of a fractured neck of femur, following earlier unwitnessed falls and an attendance at the hospital where no X-ray investigation was undertaken. She developed an infection following surgery, deteriorated despite medical intervention, and died from bronchopneumonia after discharge to Braeside Care Home. The principal concern was that patients were not receiving a daily senior clinician review, including during the interim period before recruitment and appointment of appropriate staff.
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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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of daily senior clinician reviews for patients
Wider context from the report “That patients, such as the deceased, were not being receiving a daily senior clinician review. I have been appraised of the developments that the Trust is aspiring to in relation to senior daily reviews and decision making and recognise the steps the Trust is taking to recruit appropriate staff to undertake such reviews. However, I remain concerned regarding what happens to patients in the interim period pending recruitment and appointment.
” 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 Prepare a medical staffing paper to improve seven-day standards for daily senior clinical review.
Verbatim wording from the response “Whilst not considered as contributory to Patricia Norfolk’s death, the necessity for daily senior clinical review did form part of the recommended actions to be taken by the Trust following its Root Cause Analysis (RCA). As outlined in the directive of Professor Makin (dated 15 March 2017), a paper on medical staffing in general and acute medicine within the Trust was prepared with a view to improving seven day standards for daily senior clinical review. This directive was provided to you under cover of a letter dated 15 March 2017.” Source location 2017-0438
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 Recruit four substantive consultant posts to increase capacity for seven-day clinical review.
Verbatim wording from the response “Ultimately improved medical staffing will achieve seven day clinical review albeit the numbers required currently will be lessened with improvement in patient flow. Recruitment into posts is on-going and a Diabetologist, a Chest Consultant and a Geriatrician will start this year, with further interviews planned. £10 million of funding for new consultant posts has been agreed by our Salford Group colleagues.” Source location 2017-0438
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a full learning cycle on the deteriorating-patient change package.
Verbatim wording from the response “The deteriorating patient collaborative will ensure that seven day clinical review will be available to those patients medically requiring of it. Mirroring the approach adopted by our Salford Group colleagues during their successful improvement collaborative in 2008, a full cycle of learning as regard to the methodology of the change package will be completed in November 2017 following which a cohort of Innovation Wards will be selected to represent a range of divisions and specialities across the organisation. These Innovation Wards will become the early adopters of the change package and will inform as to its spread and sustainability which will in turn inform the Trust-wide roll out of the successful interventions.” Source location 2017-0438
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 Select Innovation Wards to adopt the deteriorating-patient change package.
Verbatim wording from the response “The deteriorating patient collaborative will ensure that seven day clinical review will be available to those patients medically requiring of it. Mirroring the approach adopted by our Salford Group colleagues during their successful improvement collaborative in 2008, a full cycle of learning as regard to the methodology of the change package will be completed in November 2017 following which a cohort of Innovation Wards will be selected to represent a range of divisions and specialities across the organisation. These Innovation Wards will become the early adopters of the change package and will inform as to its spread and sustainability which will in turn inform the Trust-wide roll out of the successful interventions.” Source location 2017-0438
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement improved medical staffing to support seven-day clinical review.
Verbatim wording from the response “Having considered the content of the letter and its enclosures, including the directive of Professor Makin, you subsequently highlighted that no corresponding timescale was attached to the stated aspiration of the Trust to deliver daily senior clinical decision making and sought further information. This information was provided within an email dated 26 May which provided you with a timescale for the implementation of improved daily senior clinical decision making, namely following the completion of the recruitment process of two new substantive consultant posts, estimated at that time to be September 2017. The precursor to these posts was Trust Board agreement to the paper prepared by Professor Makin and provision of funding for the two new substantive posts.” Source location 2017-0438
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 Trust considered the actions within its power to improve daily senior clinical review already taken and communicated, requiring no additional response work.
Verbatim wording from the response “The use of your PFD Report has not had any meaningful practical effect on the improvement of public safety given the actions within the Trust’s power to take have already been taken and communicated to you in advance of you issuing your PFD Report. Furthermore, the PFD Report’s practical effect is questionable given the date for the Trust’s response loosely coincides with the date originally envisaged for the implementation of improved medical staffing.” Source location 2017-0438
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 Trust could not realistically provide daily senior clinical review to all patients because medical staffing constraints were outside its control.
Verbatim wording from the response “The Trust acknowledges that the action as per the RCA report for ‘all patients to receive a daily senior clinician review’ was, with hindsight, more aspirational than realistically achievable due to circumstances outside its control, as detailed above. This has been fed back to those responsible for the action plan, for reflection when considering future actions.” Source location 2017-0438
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 Further action on daily senior clinical review without recruitment should be addressed to the Secretary of State for Health as a national issue.
Verbatim wording from the response “Whilst the Trust has taken steps to address this within its locality, as previously indicated, this is a national issue and consequently any steps to address your concern as to daily senior clinical review in the absence of recruitment such as that undertaken by the Trust would more appropriately addressed to The Rt Hon Jeremy Hunt MP, Secretary of State for Health.” Source location 2017-0438
Open published response
8 Mar 2017 Mrs Kathleen Cooper · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 15 Delays in arranging urgent tests and treatment View source Absence of clinical judgement caused by over-reliance on early warning tools View source Poor ward-level leadership and supervision of nurses View source Difficulties in providing safe and effective care across split hospital sites View source Failure by doctors and nurses to escalate patient deterioration View source Failure to make timely progress in addressing previously recognised care failings View source Impact of split-site commitments and reconfiguration on patient safety and clinical care View source Poor communication between clinicians and nurses View source Inadequate on-call consultant supervision of junior colleagues View source Inaccurate and incomplete fluid balance charts View source Poor medical and nursing record keeping View source Failure to repeat indicated tests and act on the results View source Unsafe standard of hospital care out of hours and at weekends View source Failure to record accurate baseline observations and vital parameters View source Incorrect calculation of early warning scores View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Kathleen Cooper · 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 Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging urgent tests and treatment
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics )
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of clinical judgement caused by over-reliance on early warning tools
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor ward-level leadership and supervision of nurses
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in providing safe and effective care across split hospital sites
Wider context from the report “1. During the course of the inquest, a medical practitioner raised concerns regarding the difficulties faced by clinicians in providing safe and effective care when an acute NHS Trust has a number of hospitals/departments on different sites i.e. the difficulties faced as a result of split-site commitments as a result of NHS reconfiguration . I echo this concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by doctors and nurses to escalate patient deterioration
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely progress in addressing previously recognised care failings
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months . Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths . My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Impact of split-site commitments and reconfiguration on patient safety and clinical care
Wider context from the report “4. Split site commitment/reconfiguration and the impact this potentially has upon patient safety and clinical care (please see 1 above).
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication between clinicians and nurses
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate on-call consultant supervision of junior colleagues
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete fluid balance charts
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor medical and nursing record keeping
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat indicated tests and act on the results
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe standard of hospital care out of hours and at weekends
Wider context from the report “2. The standard of care provided to hospital patients out of hours/weekend and the risk/s posed to patient safety as a result.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record accurate baseline observations and vital parameters
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect calculation of early warning scores
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report
7 Sep 2016 Dildar Shariff · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines View source Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure 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
Dildar Shariff · 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
Dildar Shariff died at Fairfield General Hospital on 10 May 2016 after a cardiac arrest, following a fall, head pain and vomiting. An intracerebral haemorrhage was confirmed, and the report states that his haemodialysis placed him at increased risk of haemorrhage. The principal concern was that this risk was not widely recognised or referred to in the relevant NICE guidelines, potentially creating a risk to other patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines
Wider context from the report “Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure
Wider context from the report “Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines.
” Open source report
30 Jun 2016 baby Dominic Smith · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to act on early warning scores View source Failure to carry out maternal observations after delivery despite a temperature spike View source Failure to recognise signs and symptoms of neonatal deterioration View source Inadequate clinical communication and handover View source Inadequate preceptorship for newly qualified and part-time midwives View source Failure of midwives to escalate to or consult with relevant specialist clinicians View source Failure to carry out speculum examination to establish rupture of membranes View source Failure to document rationale for clinical discretion View source Failure to carry out neonatal observations after material change in condition View source Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests View source Failure of staff to follow clinical protocols and guidance View source Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy View source Miscalculation of early warning scores View source Inadequate clinical record keeping View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
baby Dominic Smith · 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
Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon ;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out maternal observations after delivery despite a temperature spike
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature ;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise signs and symptoms of neonatal deterioration
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed ;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical communication and handover
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate preceptorship for newly qualified and part-time midwives
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of midwives to escalate to or consult with relevant specialist clinicians
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out speculum examination to establish rupture of membranes
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes . The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document rationale for clinical discretion
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion ;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out neonatal observations after material change in condition
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition . Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to follow clinical protocols and guidance
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy ,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Miscalculation of early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated , ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical record keeping
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping ;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report
6 Apr 2016 Milly ZEMMEL · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Failure to initiate appropriate one-to-one supervision and observations View source Inadequate internal investigation of failures in basic medical care View source Failure to hand over important clinical information to the next shift View source Failure to assess and correctly apply the falls risk policy View source Failure to escalate required clinical review after a fall View source Failure to check patient records for up-to-date information at shift change View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Milly ZEMMEL · 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
Milly ZEMMEL, who was blind and aged 89, was admitted to hospital after becoming unwell and later suffered falls, including an unwitnessed fall on 1 March 2015 while experiencing acute confusion. She fractured her left femur, was not considered fit for surgery, and died on 3 March 2015. The principal concerns were failures in falls-risk assessment, escalation and handover after an earlier fall, appropriate supervision and observations, and the adequacy of the hospital’s internal investigation.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate appropriate one-to-one supervision and observations
Wider context from the report “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate internal investigation of failures in basic medical care
Wider context from the report “1. The Trust’s own internal investigative procedures were demonstrably inadequate because the internal hospital investigation did not fully and properly identify the gross failure to provide the deceased with the basic medical care which her condition obviously required on the morning of 1 March 2015. The full particulars only became apparent when evidence was heard at the inquest and the records were checked. The gravity of the failings in care had not been properly identified .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over important clinical information to the next shift
Wider context from the report “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift . Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and correctly apply the falls risk policy
Wider context from the report “2. There have been failures to assess and correctly apply the then existing falls risk policy .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate required clinical review after a fall
Wider context from the report “3. There was a failure to escalate the requirement for a clinical review following her fall on 21 February 2015 and nor was this identified at handovers on several occasions .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check patient records for up-to-date information at shift change
Wider context from the report “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was . Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch and disseminate the Clinical Communication and Handover Policy with structured escalation and handover documentation.
Verbatim wording from the response “The Trust launched a policy for Clinical Communication and Handover in September 2015 which includes handover documentation templates with more robust information for recording safety concerns such as a patient who may be at risk of falls information and a standard framework for escalating concerns about a patient. The policy also includes the standard required for doctor to doctor handovers including for patients who have been referred and who need to be assessed. The policy has been disseminated across the clinical teams in the Trust and the senior nursing team undertake quarterly audits to assess the quality and level of compliance. This policy is within Appendix 3 - Clinical Communication and Handover Policy.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Enhanced Patient Observation Policy to guide safe supervision and observation of adult in-patients.
Verbatim wording from the response “The Enhanced Patient Observation Policy was also introduced in February 2016 to ensure patient safety and to help provide the appropriate level of supervision and observation for adult in-patients. This policy provides advice and support to staff on the different requirements and needs of patients who require observation. This can be found in Appendix 6 - Enhanced Patient Observation Policy.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of compliance with the Clinical Communication and Handover Policy.
Verbatim wording from the response “The Trust launched a policy for Clinical Communication and Handover in September 2015 which includes handover documentation templates with more robust information for recording safety concerns such as a patient who may be at risk of falls information and a standard framework for escalating concerns about a patient. The policy also includes the standard required for doctor to doctor handovers including for patients who have been referred and who need to be assessed. The policy has been disseminated across the clinical teams in the Trust and the senior nursing team undertake quarterly audits to assess the quality and level of compliance. This policy is within Appendix 3 - Clinical Communication and Handover Policy.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an investigation toolkit covering investigation processes and report preparation.
Verbatim wording from the response “• To accompany the RCA training programme the Clinical Governance team have also developed an investigation toolkit that covers all aspects of investigations and advice on preparing and writing investigation reports.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require nursing staff to escalate urgent medical reviews through the specified clinical escalation route and use the SBAR communication tool.
Verbatim wording from the response “Failure to act and escalate the lack of medical review will be included in the Lessons Learned Bulletin within the Medical Division and disseminated to all wards and departments across the division. The learning for nursing staff is to escalate to the medical team and in the first instance to the registrar and then consultant or on call Consultant, with assistance if required from within the senior nursing site team or on call/ bleep holder out of hours to ensure that any request for urgent review occurs. Staff will be required to use the communication handover SBAR tool (situation, background, assessment and recommendation) to support any communication. This is contained within the Clinical Communication and Handover Policy.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
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 Train 103 staff, including senior clinicians and managers, in root cause analysis.
Verbatim wording from the response “• A two day programme of root cause analysis training was commissioned by an external company specialising in root cause analysis (RCA) training and 103 staff, including senior clinicians and managers, were trained during 2015/16. In addition the Trust delivered training on Duty of Candour (being open) to ensure that patients and families receive support and feedback when a serious incident investigation is commenced. An internal programme of investigation training will continue throughout 2016/17 to ensure that the quality and breadth of Trust investigations continues to improve.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
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 Include learning about failures to obtain and escalate medical review in the Medical Division Lessons Learned Bulletin and disseminate it across wards and departments.
Verbatim wording from the response “Dissemination of Lessons Learned” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Safety Huddles at the start of ward and departmental shifts to discuss incidents, safety issues and enhanced observation needs.
Verbatim wording from the response “The Trust has piloted and now introduced a ‘Safety Huddle’ at the commencement of each ward and departmental shift which includes the discussion and handover of any recent incidents, as well as safety issues relating to patients. This includes a prompt for discussion of any patients who will require additional observation or enhanced supervision as part of their care. This allows nursing staff to report on any unexpected and significant events involving patients and helps them to proactively plan and agree how to resolve them. The policy is within Appendix 2 - Safety Huddle document.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
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 and launch the Incident Reporting and Investigation Policy and require independent investigation teams for serious incidents.
Verbatim wording from the response “It was recognised early in 2015 that the Trust need to make improvements in how investigations were conducted within the organisation. An external review of serious incident investigations was commissioned by the former Chief Executive and following this review the Trust instigated a number of actions:” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Fallsafe Policy with assessment, care-planning and care-bundle tools, supported by staff training.
Verbatim wording from the response “The new Fallsafe Policy for the prevention and management of in-patient falls was introduced in April 2016; this includes newly launched tools for assessment, care planning and a care bundle. As part of the launch, training was included using the Fallsafe resources produced by the Royal College of Physicians and is available to all staff.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the internal investigation training programme throughout 2016/17.
Verbatim wording from the response “• A two day programme of root cause analysis training was commissioned by an external company specialising in root cause analysis (RCA) training and 103 staff, including senior clinicians and managers, were trained during 2015/16. In addition the Trust delivered training on Duty of Candour (being open) to ensure that patients and families receive support and feedback when a serious incident investigation is commenced. An internal programme of investigation training will continue throughout 2016/17 to ensure that the quality and breadth of Trust investigations continues to improve.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
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 Employ two falls specialist practitioners to enhance staff education and training and develop falls-management systems.
Verbatim wording from the response “The Trust has now employed two Specialist Practitioners for falls to further enhance and develop the systems and processes for the education and training of staff. Part of their work will be to develop the processes for patient risk assessment and for auditing the implementation and effectiveness of the policy in clinical areas. The Fallsafe Policy is in Appendix 4 and the Fallsafe staff information booklet is within at Appendix 5.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop patient risk-assessment processes and audit Fallsafe Policy implementation and effectiveness.
Verbatim wording from the response “The Trust has now employed two Specialist Practitioners for falls to further enhance and develop the systems and processes for the education and training of staff. Part of their work will be to develop the processes for patient risk assessment and for auditing the implementation and effectiveness of the policy in clinical areas. The Fallsafe Policy is in Appendix 4 and the Fallsafe staff information booklet is within at Appendix 5.” Source location 2016-0139-Response-Pennine-Acute-Hospitals
Open published response
15 Jul 2015 Joyce Hartford · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure of nurse record-keeping audits to produce material improvement in standards View source Incomplete or inaccurate nursing records and associated documentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joyce Hartford · 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
Joyce Hartford, described as a frail woman with pre-existing co-morbidities, suffered a fall causing a fracture that required surgery. Her health deteriorated and she died at home on 23 January 2015; the medical cause of death included pneumonia, an operated right neck of femur osteoporotic fracture, and caecal carcinoma. The inquest identified incomplete or inaccurate nursing tools, assessments, records, associated documentation, and the nursing discharge summary, with concerns that record-keeping standards had not materially improved.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nurse record-keeping audits to produce material improvement in standards
Wider context from the report “1. During the course of the inquest hearing it became apparent that the nursing tools (in particular, the ‘Purpose T’), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate. Whilst I was told that the Trust, to its credit, had been conducting audits since the Summer of 2014 in order to improve nurse record keeping , Mrs Hartford died in January 2015 and the evidence at inquest did not disclose any material improvement in overall standards .
As this was not the first case over which I had presided that involved concerns arising from record keeping that fell below expectation (over and above the aforementioned) I considered that I was under an obligation to bring this to your attention.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete or inaccurate nursing records and associated documentation
Wider context from the report “1. During the course of the inquest hearing it became apparent that the nursing tools (in particular, the ‘Purpose T’), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate . Whilst I was told that the Trust, to its credit, had been conducting audits since the Summer of 2014 in order to improve nurse record keeping, Mrs Hartford died in January 2015 and the evidence at inquest did not disclose any material improvement in overall standards.
As this was not the first case over which I had presided that involved concerns arising from record keeping that fell below expectation (over and above the aforementioned) I considered that I was under an obligation to bring this to your attention.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing and governing nursing documentation through the Nursing Documentation Group and Nursing and Midwifery Board, including wider professional documentation.
Verbatim wording from the response “• Over the last 12 months we have also reviewed the process of developing, reviewing and ratifying nursing documents to implement a more rigorous governance process through our Nursing Documentation Group and the Nursing and Midwifery Board. This project is ongoing. The Nursing Documentation Group has widened its remit to cover Allied Health Professionals and Maternity documentation. The main objective is to align documentation control and development processes across specialties.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Nursing Metrics across the Trust to audit nursing-documentation quality in case notes.
Verbatim wording from the response “• Over the past 18 months Nursing Metrics have been introduced, part of which involves audit of the quality of nursing documentation in the case notes.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit registered nurses to Ward T7 and provide induction competency observations covering documentation and related clinical tasks.
Verbatim wording from the response “• Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently – this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools (involves nursing staff using predetermined questions to ask patients on a regular basis about care needs and includes checks on the patient environment.)” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the EVOLVE electronic case-note system, beginning with a pilot of nursing assessments, care plans, referrals and specified risk documentation.
Verbatim wording from the response “• The Trust has also commenced the implementation of the ‘EVOLVE’ system which will introduce electronic records across the Trust. This will be piloted later this year and is projected to start on 17th November and run for 4 weeks with a Trust wide rollout projected to take 4 months starting in January 2016. The Project brief is to replace all clinical documentation with electronic forms hosted within the Evolve electronic case-note system. This will help mandate the completion of key patient assessments. The first phase of forms to be piloted on two wards at NMGH will focus on nursing assessment documents, associated care plans and referrals and will include nutritional assessments, falls and bed rails risk assessments, dementia screening and the pressure ulcer care plan.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure Trust Development Agency support and carry out a Trust-wide documentation standardisation project.
Verbatim wording from the response “• With the support of the Chief Nurse, we have now secured support of a team from the Trust Development Agency to help improve record keeping and a Trust wide documentation standardisation project is underway.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement scenario training on completing the Purpose T tool for early pressure-ulcer detection and management.
Verbatim wording from the response “• For early detection and management of pressure ulcers the use of scenario training on the completion of the Purpose T tool is now in place. The introduction of an air flow mattress store on the unit now ensures that patients who have suffered a fractured neck of femur are admitted to the Unit from A&E directly onto a ‘pre-socio’ mattress.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Ward T7 documentation against Trust standards and conduct monthly nursing-metrics audits of record keeping.
Verbatim wording from the response “• We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly Ward T7 documentation audits with immediate feedback on risk assessments, care plans and reassessments.
Verbatim wording from the response “• There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at the time of the audit. These include accurate and timely completion of risk assessments, use of appropriate care plans and timely reassessments.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Ward Accreditation to monitor ward-team nursing-care quality, including record keeping and patient assessments.
Verbatim wording from the response “• The Trust is also introducing Ward Accreditation, a new project which will help us to monitor safe practice by measuring the quality of nursing care delivered by ward teams. As part of this project we will be checking and monitoring the quality of record keeping including patient assessments.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run Nursing Care Indicators audits and respond to reduced results through corrective action.
Verbatim wording from the response “• Since February 2015, the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for May when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating nursing documentation within the medical records. This was addressed and results improved to 92% in June, 95% in July and 93% in August.” Source location 2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Open published response
9 Jul 2015 Toni Piel · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to assess home circumstances and available observation when discharging patients following head injury View source Failure to document discharge risk-factor assessments in clinical records 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
Toni Piel · 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
Toni Piel suffered a head injury in a fall at home on 10 December 2014 and was treated at hospital before being discharged. He was found dead at home on 23 December 2014, with the inquest concluding that he died from a head injury caused by a fall, although it was not established whether this was linked to the earlier injury. Concerns included that his home circumstances and the absence of anyone able to observe him were apparently not considered at discharge, and that risk factors were not documented.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess home circumstances and available observation when discharging patients following head injury
Wider context from the report “i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account . Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home . The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account.
ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document discharge risk-factor assessments in clinical records
Wider context from the report “i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account.
ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records.
” Open source report
31 Mar 2015 Thomas Beaty · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Difficulty for Trusts to change guidance without external guidance improvement View source Use of misleading and clinically inappropriate ‘gentle’ traction terminology View source Lack of operational definitions for instrumental-delivery terminology View source Ambiguity in guidance on when to abandon instrumental delivery View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Thomas Beaty · 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
Thomas Beaty was born by emergency caesarean section after an abandoned instrumental delivery on 11 April 2014. At 26 hours of age, he suffered a catastrophic head injury, hypovolaemic shock and hypoxic brain ischaemia, and died. The report raised concerns that guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, including unclear terminology and misleading guidance about traction.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty for Trusts to change guidance without external guidance improvement
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of misleading and clinically inappropriate ‘gentle’ traction terminology
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of operational definitions for instrumental-delivery terminology
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in guidance on when to abandon instrumental delivery
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” Open source report
13 Mar 2015 Mr James Mc Manus · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of staff knowledge, application and implementation of guidelines for managing bleeding associated with thrombolytic therapy View source Lack of staff knowledge, application and implementation of protocols for managing massive blood loss View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr James Mc Manus · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr James Mc Manus was admitted with acute lower limb ischaemia requiring thrombolysis and subsequently developed bleeding and hypovolaemic shock. He died on 3 November 2013 following recognised but rare complications of medical intervention; concerns included failures to follow protocols for managing thrombolytic-associated bleeding and massive blood loss.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge, application and implementation of guidelines for managing bleeding associated with thrombolytic therapy
Wider context from the report “1. I am concerned about the lack of knowledge, application and implementation of key protocols by Trust staff – in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of massive blood loss.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge, application and implementation of protocols for managing massive blood loss
Wider context from the report “1. I am concerned about the lack of knowledge, application and implementation of key protocols by Trust staff – in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of massive blood loss .
” 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 Deliver mandatory training on thrombolysis policies and associated bleeding risks to medical staff.
Verbatim wording from the response “• Development of a training presentation incorporating the policies and guidelines regarding Thrombolysis and management of associated bleeding risks. This presentation will take place on 22nd May 2015, during the Clinical Governance Audit session, attendance is mandatory for all levels of medical staff. ████████, Vascular Surgeon and ████████ Clinical Lead for Anaesthetics will lead on this presentation. Prior to the audit day the Directorate Manager for Vascular Surgery will ensure that all levels of Vascular medical staff receive copies of the policies to be discussed.” Source location 2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver thrombolysis and bleeding-risk training to Critical Care staff.
Verbatim wording from the response “• New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology Consultants. The session dates were held on the following dates, 14th and 27th October 2014 and on 10th and 24th November 2014.” Source location 2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate and maintain the new thrombolysis policy on the Trust intranet.
Verbatim wording from the response “• New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology Consultants. The session dates were held on the following dates, 14th and 27th October 2014 and on 10th and 24th November 2014.” Source location 2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Open published response
16 Feb 2015 infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to disseminate the Trust’s Interpreting Policy to staff View source Lack of national guidelines for interpreting and classifying antenatal CTG tracings View source Failure of the Trust’s Interpreting Policy to provide applicable guidance on obtaining informed consent View source Failure by staff to apply the Trust’s Interpreting Policy View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · 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
Infant Rahat Qayyum was delivered in very poor condition on 5 July 2013 after abnormalities on CTG traces were not fully recognised, and died on 19 July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia. The concerns identified included the absence of national guidelines for interpreting antenatal CTG tracings and issues concerning the dissemination, application and applicability of the Trust’s Interpreting Policy, particularly in relation to informed consent.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate the Trust’s Interpreting Policy to staff
Wider context from the report “2. The dissemination , application and applicability of the Trust’s Interpreting Policy, by its staff , in force at the material time (with particular regard to the obtaining of informed consent).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for interpreting and classifying antenatal CTG tracings
Wider context from the report “1. Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Trust’s Interpreting Policy to provide applicable guidance on obtaining informed consent
Wider context from the report “2. The dissemination, application and applicability of the Trust’s Interpreting Policy , by its staff, in force at the material time (with particular regard to the obtaining of informed consent ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by staff to apply the Trust’s Interpreting Policy
Wider context from the report “2. The dissemination, application and applicability of the Trust’s Interpreting Policy, by its staff , in force at the material time (with particular regard to the obtaining of informed consent).
” Open source report
26 Nov 2013 Barry James LEWIS · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Inconsistency of instrumental content within packs View source Inadequate night staffing levels of ODTs View source Inadequacy or unavailability of emergency airway surgical sets containing instruments of different sizes View source Limited out-of-hours accessibility of theatres to obtain additional instrumentation View source Inadequacy or unavailability of additional individually packed surgical instrumentation as back-up to standard sets View source Lack of familiarity with the instrumental content of packs View source Inadequate out-of-hours medical cover for ENT service provision View source Inadequate medical cover for geographic or split-site commitments View source See 5 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
Barry James LEWIS · 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
Barry James Lewis suffered an anaphylactic reaction of unknown origin and developed severe airway swelling and difficulty speaking. Despite emergency treatment, attempts to secure his airway were difficult, he suffered respiratory and cardiac arrest, and he died after 50 minutes of resuscitation. The substantive concerns related to the availability and suitability of emergency airway instruments, theatre access, night staffing, and out-of-hours ENT cover across multiple sites.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency of instrumental content within packs
Wider context from the report “2) The consistency of instrumental content within the packs and familiarity with the same.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate night staffing levels of ODTs
Wider context from the report “5) Night staffing levels – in particular, the adequacy/sufficiency of ODTs .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy or unavailability of emergency airway surgical sets containing instruments of different sizes
Wider context from the report “1) The adequacy/availability of emergency airway surgical sets, containing instruments of different sizes, within the ER department . The ‘one size fits all’ approach raises patient safety issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited out-of-hours accessibility of theatres to obtain additional instrumentation
Wider context from the report “4) The accessibility of theatres in order to obtain additional instrumentation when needed, out of hours .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy or unavailability of additional individually packed surgical instrumentation as back-up to standard sets
Wider context from the report “3) The adequacy and availability of additional, individually packed surgical instrumentation within the ER, as ‘back-up’ to the standard sets (e.g. larger retractors, scalpels etc.)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of familiarity with the instrumental content of packs
Wider context from the report “2) The consistency of instrumental content within the packs and familiarity with the same .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate out-of-hours medical cover for ENT service provision
Wider context from the report “6) Staffing levels/adequacy/sufficiency of medical cover , with particular reference to ENT service provision out of hours and geographic/split site commitments.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical cover for geographic or split-site commitments
Wider context from the report “6) Staffing levels/adequacy/sufficiency of medical cover , with particular reference to ENT service provision out of hours and geographic/split site commitments .
” 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 Review night nurse practitioners’ role to involve them in direct care and management of critically ill patients.
Verbatim wording from the response “4) The role of the night nurse practitioners has been reviewed to ensure that they would be involved in the direct care & management of such critically ill patients to ensure that others are released to do what they in turn are needed to do e.g. ODP’s.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement flexible team working to support ODPs and enable other staff to perform their required duties.
Verbatim wording from the response “4) The role of the night nurse practitioners has been reviewed to ensure that they would be involved in the direct care & management of such critically ill patients to ensure that others are released to do what they in turn are needed to do e.g. ODP’s.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and standardize emergency airway packs across A&E departments, including large instruments and ENT clinician input.
Verbatim wording from the response “1) The emergency airways packs have been up dated in all the A&E departments at the trust to ensure that they have ‘large’ instruments for the overweight patients.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increasing ODP staffing at Fairfield is considered neither clinically nor financially practical.
Verbatim wording from the response “5) The availability of ODP’s for Fairfield is appropriate for the volume of surgical activity it receives. As per 4) it is important that other members of the team work flexibly to support them. This has been implemented. To increase ODP levels is neither practical clinically or financially.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A&E departments cannot stock theatres’ full specialist equipment range, so specialist equipment must sometimes be obtained from elsewhere.
Verbatim wording from the response “3) As before ‘large’ scalpels & retractors are available. It does however need to be noted that A&E departments will never be in a position to stock the same range of equipment as theatres in addition to the wide variety of other equipment they have for day to day use. As such arrangements will not remove the need on occasions for more specialist equipment which cannot be stocked to be obtained from other areas.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Out-of-hours staffing and ENT cover are considered appropriate for the site and trust’s activity.
Verbatim wording from the response “6) Out of hours staffing, like that for ODP’s, is appropriate for the site & the trust. With particular reference to ENT cover it would again neither be clinically or financially practical to have more than one person on call at middle grade level for the trust for the level of activity in that specialty. Where there is a clinical need the consultant would be contacted & asked to come in. As you are aware the trend in medicine is for there to be fewer specialist sites which cover a wider catchment population. Other specialties where this has happened would include cardiothoracic surgery, vascular surgery, ophthalmology, urology & neurosurgery.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation More than one trust-wide middle-grade ENT clinician on call is considered neither clinically nor financially practical.
Verbatim wording from the response “6) Out of hours staffing, like that for ODP’s, is appropriate for the site & the trust. With particular reference to ENT cover it would again neither be clinically or financially practical to have more than one person on call at middle grade level for the trust for the level of activity in that specialty. Where there is a clinical need the consultant would be contacted & asked to come in. As you are aware the trend in medicine is for there to be fewer specialist sites which cover a wider catchment population. Other specialties where this has happened would include cardiothoracic surgery, vascular surgery, ophthalmology, urology & neurosurgery.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ODP availability at Fairfield is considered appropriate for its surgical activity, with flexible teamwork supporting available staff.
Verbatim wording from the response “5) The availability of ODP’s for Fairfield is appropriate for the volume of surgical activity it receives. As per 4) it is important that other members of the team work flexibly to support them. This has been implemented. To increase ODP levels is neither practical clinically or financially.” Source location 2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
21 Nov 2013 Jack William PARTINGTON · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Lack of national standardised guidance on the management of ventilation in neonates View source Failure to routinely check medical records for new neonatal admissions View source Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU View source Failure to ensure effective oversight and monitoring of the ventilatory pressure dial following intubation View source Lack of national standardised guidance on the management and administration of paralysing agents to neonates needing intubation View source Failure to make treatment decisions collaboratively and using all available information View source Lack of individualised neonatal nursing care plans View source Failure to provide 1:1 neonatal nurse/cotside handover at shift change View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jack William PARTINGTON · 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
Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national standardised guidance on the management of ventilation in neonates
Wider context from the report “4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check medical records for new neonatal admissions
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU
Wider context from the report “3) That disposable exhaled carbon dioxide detectors (ET CO2) were not routinely used on the NNU (as an adjunct) and that they are not currently/routinely used in many NNUs throughout the country.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective oversight and monitoring of the ventilatory pressure dial following intubation
Wider context from the report “5) No single individual within the neonatal (resuscitation) team was allocated to oversee and monitor the ventilatory pressure dial following intubation. The dial in question was situated on the side of the incubator/cot, out of the direct line of sight of the clinician controlling the airway/ventilatory 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national standardised guidance on the management and administration of paralysing agents to neonates needing intubation
Wider context from the report “4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make treatment decisions collaboratively and using all available information
Wider context from the report “2) Nursing staff, rather than the multi-disciplinary team plus parents, took treatment/change of treatment decisions in isolation and without consulting all available information (such as medical records etc.)
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of individualised neonatal nursing care plans
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions.
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide 1:1 neonatal nurse/cotside handover at shift change
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change , no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions.
” Open source report
20 Aug 2013 Derek BRIERLEY · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Difficulties in locating suprapubic catheters before procedures View source Suprapubic catheter insertion at an excessively high site View source Lack of Trust guidelines for competence and training in suprapubic procedures View source Failure to ensure current competence for suprapubic procedures 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
Derek BRIERLEY · 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
Derek Brierley’s urethral catheter became blocked and attempts to recatheterise him were unsuccessful, including an abandoned suprapubic catheter insertion, after which he became acutely unwell with features of peritonitis. Concerns included the likely high insertion site, the absence of Trust guidelines on competence and training for the procedure, and difficulties locating a suprapubic catheter beforehand.
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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in locating suprapubic catheters before procedures
Wider context from the report “3)Difficulties were encountered in locating a suprapubic catheter prior to the procedure
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Suprapubic catheter insertion at an excessively high site
Wider context from the report “1) Although the consultant performing the suprapubic procedure had done so successfully on nine previous occasions the last such occasion was twelve months earlier. The family overheard instructions for the procedure being read out to the consultant whilst it was being carried out. More likely than not the site of the insertion was too high .
” 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 Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Trust guidelines for competence and training in suprapubic procedures
Wider context from the report “2) There are no Trust Guidelines as to the standard of competence or training of those carrying out the procedure
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure current competence for suprapubic procedures
Wider context from the report “1) Although the consultant performing the suprapubic procedure had done so successfully on nine previous occasions the last such occasion was twelve months earlier . The family overheard instructions for the procedure being read out to the consultant whilst it was being carried out . More likely than not the site of the insertion was too high.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement urology training and competency sign-off for clinicians inserting suprapubic catheters outside urology.
Verbatim wording from the response “3) The urology team have initiated a training program for those who may need to insert such catheters outside of the urology division. Individuals will need to be signed off for this, (a process we already use for chest drains).” Source location 2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Label, regularly check and appropriately store suprapubic catheter procedure trays.
Verbatim wording from the response “8) Procedure trays are clearly labelled, regularly checked & appropriately stored. Difficulty finding the kit in this case was due to individual lack of familiarity as it is not a procedure frequently performed in a very busy A&E.” Source location 2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Procedure trays are clearly labelled, regularly checked and appropriately stored, so no change to tray arrangements is identified.
Verbatim wording from the response “8) Procedure trays are clearly labelled, regularly checked & appropriately stored. Difficulty finding the kit in this case was due to individual lack of familiarity as it is not a procedure frequently performed in a very busy A&E.” Source location 2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The difficulty locating the procedure kit resulted from individual unfamiliarity, not inadequate tray labelling, checking or storage.
Verbatim wording from the response “8) Procedure trays are clearly labelled, regularly checked & appropriately stored. Difficulty finding the kit in this case was due to individual lack of familiarity as it is not a procedure frequently performed in a very busy A&E.” Source location 2013-0244-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations