Concerns raised 3 Failure to ensure specialist bariatric team review of post-operative gastric bypass patients View source Failure of non-specialist medical staff to recognise the significance of post-operative pain View source Failure to escalate increased abdominal pain to a senior doctor within 2 hours 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
Susan EVANS · 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
Susan Evans underwent elective gastric bypass surgery on 11 July 2023, developed abdominal pain, was discharged without review by the specialist bariatric team or a senior doctor, and was later readmitted with abdominal sepsis from an anastomotic leak. She died at Queen Alexandra Hospital on 12 August 2023. The principal concern was that the hospital’s written and informal policies for specialist review and escalation of pain were not followed, which the inquest found contributed more than minimally to her death.
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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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure specialist bariatric team review of post-operative gastric bypass patients
Wider context from the report “Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that:
- There is to be a daily review by a bariatric specialist nurse, consultant or registrar.
- A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed.
In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy.
Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all.
The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain.
The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of non-specialist medical staff to recognise the significance of post-operative pain
Wider context from the report “Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that:
- There is to be a daily review by a bariatric specialist nurse, consultant or registrar.
- A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed.
In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy.
Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all.
The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain.
The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate increased abdominal pain to a senior doctor within 2 hours
Wider context from the report “Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that:
- There is to be a daily review by a bariatric specialist nurse, consultant or registrar.
- A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed.
In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy.
Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all.
The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain.
The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern.
” 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 Further disseminate the Bariatric Discharge Protocol at the Biannual AGM, nursing surgical study day and surgical ward-level safety huddles.
Verbatim wording from the response “The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025.” Source location Response from Portsmouth Hospital 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 Disseminate the Bariatric Discharge Protocol through surgical governance and team meetings and email it to surgical staff with bariatric out-of-hours or emergency responsibility.
Verbatim wording from the response “The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025.” Source location Response from Portsmouth Hospital NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Bariatric Discharge Protocol in the pathway booklet requiring pre-discharge specialist review, pain-control assessment, discharge criteria and consultant discussion when criteria are unmet.
Verbatim wording from the response “In response to the concerns set out above, there is already a policy in place which covers points 1 and 2. Unfortunately, on this occasion, it was sadly not followed. At least in part, because it was not clearly visible in the patient’s ward notes to act as a prompt. To counter this, the Bariatric lead surgeon has written a Bariatric Discharge Protocol (the new protocol) which has been incorporated into the bariatric pathway booklet which is completed for each patient undergoing bariatric surgery and kept in their medical notes for use by treating clinicians (doctors and nurses). This protocol requires a member of the bariatric team or suitable clinician to review the patient prior to discharge and ensure the patient’s pain is settling and controlled with suitable analgesia prior to discharge.” Source location Response from Portsmouth Hospital NHS Trust
Open published response
Concerns raised 7 Failure to complete and store mental health unit handover records in SystmOne View source Lack of structured arrival handover and risk-history enquiry for detained patients View source Failure to securely store and share Queen Alexandra Hospital mental health records View source Failure to routinely flag patient risks in the Oceana records system View source Failure to properly record, store or audit paper observations and records View source Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements View source Lack of timely cross-local access to relevant electronic patient records View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jack FARRINGTON · 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 Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.
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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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and store mental health unit handover records in SystmOne
Wider context from the report “I heard evidence that the staff within the secure mental health unit rely very heavily on information given at handovers at the start of a shift and they do not have time to review the patient records in detail. At the time of Jack’s death records of these handovers were not stored in the same way as other patient records and, in Jack’s case, were missing entirely. This significantly hampered the investigation and inquest.
I am pleased to hear that Solent NHS Trust have now changed their document storage policy in this regard and these records will now be added to and stored on SystmOne.
However the handover records are not currently completed within SystmOne . This gives rise to the continuing risk of this information not being correctly recorded or correctly stored . I understand that this requires a change to SystmOne which is not yet complete.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured arrival handover and risk-history enquiry for detained patients
Wider context from the report “I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patients history of absconding or self harm . This gives rise to the possibility of a patient’s risk not being properly assessed .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to securely store and share Queen Alexandra Hospital mental health records
Wider context from the report “There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This significantly hampered the investigation and restricted the information available to the jury.
I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing records are now kept within an Enhanced Care Plan but this is still a paper format and therefore the risk of inadequate information sharing and failing to store records remain .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely flag patient risks in the Oceana records system
Wider context from the report “I heard in evidence that it is possible for patient risks to be ‘flagged’ within the Oceana records system to ensure that all staff are made aware of these. This was not done in Jack’s case and that this was not done as a matter of course , The Acting Medical Director was not aware of an established policy or procedure about using this existing functionality .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record, store or audit paper observations and records
Wider context from the report “Solent NHS Trust still relies on paper forms for some observations and record keeping within the mental health unit . In Jack’s case these were not scanned and stored which hampered the investigation and inquest. There remains a risk that where paper records are kept information is not properly recorded, stored or audited .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements
Wider context from the report “A ‘Mental Health Primary Disturbance Survey’ tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk based decisions that such guards were not necessary.
However I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding . The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely cross-local access to relevant electronic patient records
Wider context from the report “I heard evidence that there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information.
I also received evidence that the new NHS England National Record Locator system only acts as a flag to show who holds records rather than allowing access to clinicians .
This fragmentation of patient records means that medical and mental health practitioners do not have quick access to relevant information about their patients .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Verbatim wording from the response “The Trust fully agrees that the current hybrid between paper and electronic records creates greater complexity and inefficiency, impacting the ability of the multidisciplinary teams to locate all necessary information for each patient. The ambition of PHU and similar NHS Trusts who have not already done so is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time.” Source location Response from Portsmouth Hospitals University 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 Review the standardised handover, triage and risk-assessment approach to ensure self-harm and absconding risks are considered at handover.
Verbatim wording from the response “The Trust uses a Mental Health Primary Risk Assessment Survey Tool to assess patients on arrival to ED, this has been updated following this incident (see response to Q3). In addition, the use of a standardised handover triage and risk assessment tool are in review to ensure that patients’ risk of self-harm or absconding are considered at the point of handover.” Source location Response from Portsmouth Hospitals University NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Trust-wide alert policy and standard operating process linking electronic systems to flag patient needs and risks.
Verbatim wording from the response “The Trust Oceano System does have the facility to flag patients with specific needs, however there are challenges in the visibility of this for clinical staff. The Trust is undertaking an improvement programme for the way our electronic systems are used to ensure that they link with each other to flag patient needs and risks. This programme is being led by our Chief Nursing Information Officer in conjunction with divisional clinical and IT leads. This work, which is in development, will include a Trust Alert Policy and Standard Operating Process (SOP) for the use of alerts and is aimed to be in place by April 2024.” Source location Response from Portsmouth Hospitals University 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 Provide temporary staff and partner mental health teams with electronic access to document assessments and care plans in Oceano.
Verbatim wording from the response “Within the ED, bank and temporary members of staff are provided with a temporary ICT login, and a login for Oceano allowing for electronic documentation of patient assessment and delivery of care. Our partner organisations, Solent NHS Trust, and Southern Health Foundation Trust mental health teams, also now have access to Oceano allowing them to input their assessments and plan of care directly into the Trust’s ICT system negating the need for paper records.” Source location Response from Portsmouth Hospitals University 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 Locate mental health nursing records within the Enhanced Care Plan for patients awaiting mental health placement.
Verbatim wording from the response “As noted by the coroner, the Trust continues to work to improve its processes regarding the care and documentation of the care of patients with mental health needs. Patients awaiting mental health placement are predominantly cared for in the Acute Medical Unit (AMU) with the recent introduction of the mental health nursing records being located within the Enhanced Care Plan.” Source location Response from Portsmouth Hospitals University 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 Agree an implementation timeline with Solent NHS Trust for its electronic handover system.
Verbatim wording from the response “In addition to a proposed clinician-to-clinician discussion, our colleagues at Solent NHS Trust are working on developing an electronic handover system. This system will provide the ED team with more information about the patient’s needs and risks before they arrive. We will agree the timeline for implementing this system at the scheduled meeting on January 9, 2024.” Source location Response from Portsmouth Hospitals University NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an Emergency Department standard operating procedure for using mental health risk flags.
Verbatim wording from the response “We are currently addressing the specific mental health flag requirement within the ED. We are developing a local Standard Operating Procedure (SOP) that will provide guidance to clinical staff on the appropriate use of the flag. Our goal is to have this SOP in place by February 2024.” Source location Response from Portsmouth Hospitals University 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 Update the Mental Health Primary Disturbance Survey to reflect current guidance and enhanced-observation escalation requirements.
Verbatim wording from the response “We can confirm that the Trust has undertaken a full review of the Mental Health Primary Disturbance Survey in accordance with Acute Psychiatric Emergency guidance (APEx) and the Royal College of Emergency Clinicians Mental Health in Emergency Departments guidance (2023) updating the tool to reflect best practice guidance for enhanced observation requirement. The tool includes a clear guidance for escalation of concerns to senior nursing staff for support, this includes night-time and out of hours available support.” Source location Response from Portsmouth Hospitals University 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 Flag patients with mental health requirements during Emergency Department safety huddles, including risks, resources and required safety measures.
Verbatim wording from the response “We can advise that since the death of Jack Farrington the flagging of patients with a mental health requirement in the ED now occurs at the department's safety huddle which takes place every 2 hours throughout a 24-hour period. During this huddle, the department’s senior team highlight patients with a mental health requirement discussing:” Source location Response from Portsmouth Hospitals University 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 Meet with Solent NHS Trust to review transfer-of-care priorities, including clinician-to-clinician discussion before Emergency Department transfer.
Verbatim wording from the response “A meeting has been arranged with Solent NHS Trust on 9 January 2024 to review transfer of care priorities which will include clinician to clinician discussion prior to a patient’s transfer to the Emergency Department.” Source location Response from Portsmouth Hospitals University 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 Solent NHS Trust is developing the electronic handover system, with implementation timing to be agreed jointly.
Verbatim wording from the response “In addition to a proposed clinician-to-clinician discussion, our colleagues at Solent NHS Trust are working on developing an electronic handover system. This system will provide the ED team with more information about the patient’s needs and risks before they arrive. We will agree the timeline for implementing this system at the scheduled meeting on January 9, 2024.” Source location Response from Portsmouth Hospitals University 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 Security personnel are not universally required; allocation remains situation- and case-specific, based on clinical risk assessment and mental-health-team input.
Verbatim wording from the response “The allocation of security personnel to support the care of mental health patients is situation and case specific and may vary dynamically for any given individual patient. This is assessed by the local clinical team with support from the Mental Health Liaison team and regular review in the Mental Health huddle. As was discussed at the inquest, the presence of security staff can at times be provocative for Mental Health patients and cause an escalation in their distress and resultant behaviours. A collaborative approach is necessary whereby security staff work closely with mental health professionals and clinical staff to ensure a coordinated and appropriate response to patient needs, supported by risk assessments to ensure their safety and the safety of staff.” Source location Response from Portsmouth Hospitals University NHS Trust
Open published response
Concerns raised 3 Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls View source Failure to assign overall responsibility for monitoring adherence to hydration requirements View source Poor completion of nursing care plan documentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony David Blower · 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
Anthony David Blower died at home on 25 October 2020 after sustaining multiple falls, bilateral subdural haematoma and further bleeding following hospital admission and surgery. The concerns identified included nursing care-plan risk assessments not being updated, poor documentation, and inadequate oversight of hydration, with Mr Blower becoming seriously dehydrated during his admission.
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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls
Wider context from the report “1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay . I heard evidence that there are changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments . The multi factorial falls risk assessment had not been fully updated after an in-patient fall by Mr Blower .
The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes.
I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that records with documentation remained poor. The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall responsibility for monitoring adherence to hydration requirements
Wider context from the report “2) Mr Blower was found to be dehydrated and he required IV fluids during his admission. The hospital nutrition policy (section entitled hydration) states that it is the responsibility of the registered nurse and medical practitioner to ensure patients receive adequate fluids and that a minimum of 7 drinks should be provided daily.
In evidence I was informed that the nurses monitor fluid intake by keeping an eye on water levels in patients’ jugs (for those not deemed to require fluid intake charts). There is no-one on a ward with overall responsibility for ensuring that the trust policy on hydration is adhered to . Representations from the hospital state that other members of staff also keep an eye on nutrition. This was not sufficient to prevent Mr Blower from becoming seriously dehydrated .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor completion of nursing care plan documentation
Wider context from the report “1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay. I heard evidence that there are changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments. The multi factorial falls risk assessment had not been fully updated after an in-patient fall by Mr Blower.
The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes.
I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that records with documentation remained poor . The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority .
” 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 Deliver documentation education through the reviewed preceptorship programme for newly registered nurses and healthcare support workers.
Verbatim wording from the response “With regard to nursing staff, the trust has recently reviewed its preceptorship programme for all newly registered nursing staff and for the new HCSW workforce. This includes a comprehensive overview of documentation as part of a fundamentals of care education package.” Source location Response from Portsmouth Hospitals University (2)
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit completion and updating of clinical documentation.
Verbatim wording from the response “Good documentation is vital to the provision of good quality clinical care as you acknowledge above, and as is explained in the letter of 20th December 2022, (attached) the Trust does audit documentation and is in the process of updating its systems.” Source location Response from Portsmouth Hospitals University (2)
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update documentation systems to improve clinical record completeness and accessibility.
Verbatim wording from the response “Good documentation is vital to the provision of good quality clinical care as you acknowledge above, and as is explained in the letter of 20th December 2022, (attached) the Trust does audit documentation and is in the process of updating its systems.” Source location Response from Portsmouth Hospitals University (2)
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 Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Verbatim wording from the response “The current hybrid between paper and electronic records on the wards creates greater complexity and inefficiency for our staff in terms of recording information. It also leads to there being a more fragmented overall record which makes it harder for members of the multidisciplinary team to be aware of all the information that has been recorded for any given patient. The ambition of PHU and similar NHS Trusts who have not already done so, is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time.” Source location Response from Portsmouth Hospitals University (2)
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
Verbatim wording from the response “The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways.” Source location Response from Portsmouth Hospitals University
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the decision-making process on adopting electronic clinical-note forms to improve completion of mandated fields.
Verbatim wording from the response “iii) As you may be aware, the trust is currently transitioning towards an electronic solution for clinical notes (digital forms) which will enable an improvement in the completion of key mandated fields. This will be about 3-6 months in the decision-” Source location Response from Portsmouth Hospitals University
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing multidisciplinary observation, clinical assessment and selective fluid-charting arrangements are considered sufficient to monitor patients’ hydration without one overall monitor.
Verbatim wording from the response “2. I understand that at the inquest you heard evidence about the difficulties of ensuring that those patients who do not have fluid charts are offered 7 drinks a day and that nurses try and keep an eye on water jugs, etc. I understand you were concerned that no one has overall responsibility for monitoring of fluids for those patients without fluid charts.” Source location Response from Portsmouth Hospitals University
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ward accreditation and clinical audit processes are considered sufficient to address nursing documentation and care-plan completion concerns.
Verbatim wording from the response “The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways.” Source location Response from Portsmouth Hospitals University
Open published response
Concerns raised 2 Failure to flag relevant critical care information to clinicians View source Failure to make relevant critical care information accessible to clinicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Beatrice Florence May DAWKINS · 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
Beatrice Florence May DAWKINS died on 20 September 2020 at Queen Alexandra Hospital after suffering an anaphylactic reaction to chloramphenicol administered for a urinary tract infection. The principal concern was that records of her sensitivity to chloramphenicol were not readily accessible or flagged to clinicians before the medicine was administered, creating a future risk to life.
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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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag relevant critical care information to clinicians
Wider context from the report “The deceased's medical notes contained at least seven entries indicating the deceased had a sensitivity to chloramphenicol, the first such entry being recorded in 1997.
Those medical notes included notes made by the Queen Alexandra Hospital, Portsmouth in which the deceased's recorded allergies included chloramphenicol.
Evidence was adduced that had the clinicians involved in the care and treatment of the deceased in September 2020 had knowledge of those notes and/or the deceased's sensitivity to chloramphenicol had been flagged in the medical records during the deceased's September 2020 admission chloramphenicol would not have been prescribed to the deceased.
My concern is that relevant, critical information relating to the care and treatment of the deceased was in existence but was not accessible nor flagged up to those involved in the care and treatment of the deceased .
In the absence of a process where relevant, critical information is not accessible nor flagged up to clinicians there continues to be a future risk to life.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make relevant critical care information accessible to clinicians
Wider context from the report “The deceased's medical notes contained at least seven entries indicating the deceased had a sensitivity to chloramphenicol, the first such entry being recorded in 1997.
Those medical notes included notes made by the Queen Alexandra Hospital, Portsmouth in which the deceased's recorded allergies included chloramphenicol.
Evidence was adduced that had the clinicians involved in the care and treatment of the deceased in September 2020 had knowledge of those notes and/or the deceased's sensitivity to chloramphenicol had been flagged in the medical records during the deceased's September 2020 admission chloramphenicol would not have been prescribed to the deceased.
My concern is that relevant, critical information relating to the care and treatment of the deceased was in existence but was not accessible nor flagged up to those involved in the care and treatment of the deceased.
In the absence of a process where relevant, critical information is not accessible nor flagged up to clinicians there continues to be a future risk to life.
” Open source report
Concerns raised 3 Midwives' lack of awareness of the criminal offence of infant overlay involving alcohol or drugs View source Lack of continuity of care in antenatal appointments View source Lack of timely safe-sleeping information for parents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ezra James BOULTON · 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
Ezra James Boulton, aged two months, died on 20 May 2018 after being found unresponsive while co-sleeping with his mother on a sofa; alcohol had been consumed and he could not be resuscitated. The principal concerns were inadequate continuity of antenatal care, insufficient early safe-sleeping information for parents, and midwives’ lack of awareness about the legal implications of infant deaths involving co-sleeping and alcohol or drugs.
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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Midwives' lack of awareness of the criminal offence of infant overlay involving alcohol or drugs
Wider context from the report “(4) I also heard that midwives are unaware that causing the death of an infant due to co-sleeping becomes an automatic criminal offence of "overlay" (under section 1(2) of the Children and Young Persons Act 1933) if alcohol and/or drugs are involved . I believe that making this information readily available to midwifery practitioners may reduce the risk of future infant deaths due to co-sleeping but may also reduce the need for Police involvement (with a view to prosecution) in what is already a tragic time for a family who have lost their child.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care in antenatal appointments
Wider context from the report “(1) At Ezra's Inquest I was told in evidence that throughout her pregnancy (this being her first pregnancy) ████████ (Ezra's mother) did not see the same midwife twice . I believe that there should be some level of continuity of care in antenatal appointments to ensure that all of the necessary checks are preformed and appropriate antenatal advice is shared with the mother.
(2) I was also heard that ████████ own personal pregnancy was uneventful but I am concerned that the distinct lack of continuity of care appears to expose a risk that should there be any abnormalities and/or risk factors to either mother or baby as the pregnancy develops, that these have the potential to be missed; either entirely misses or not properly communicated to whichever midwife conducts the next antenatal appointment , causing significant risk to both mother and baby. I believe that there is a serious risk of future death posed by this lack of continuity of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely safe-sleeping information for parents
Wider context from the report “(3) At Ezra's inquest I was told that as baby had been delivered safely with no significant injuries to mum (i.e. no significant tearing or blood loss) that the family were encouraged to leave fairly rapidly. On discharge, the focus of information sharing and care was distinctly focused on after-care for the mother. The family did not recall being given any information directly on safe-sleeping; either at antenatal appointments or at a post-natal stage from any midwife or Health Visitor. Any information they were given was provided almost as an after-thought and given in the form of a leaflet which it was suggested that they read. I was told that the first HV appointment the family received was approximately seven weeks after Ezra had been born . I believe that making safe sleeping information readily available to all parents at an early stage may significantly reduce the risk of future infant deaths due to co-sleeping.
” 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 Alert midwifery, neonatal nursing, medical and support staff to the criminal definition of infant overlay.
Verbatim wording from the response “We recognise the importance of ensuring that midwifery staff are familiar with the components of the criminal offence of “overlay” and in response to your comments the Director of Midwifery and Maternity has emailed all midwives and neonatal nursing, medical and support staff to alert them to that definition.” Source location 2019-0222-Response-by-Portsmouth-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 Require midwives to document and confirm safe-sleeping advice on the post-birth discharge checklist.
Verbatim wording from the response “PHT has a discharge checklist sticker which is placed in the woman’s medical records following birth and includes “safe sleeping” and must be ticked by the midwife on discharge to confirm that the woman has been advised about safe sleeping. There is also a safe sleeping leaflet which is usually given to women on discharge as part of a package of advice leaflets. However, the Hampshire Safeguarding Children’s Board is currently reviewing the Safe Sleeping Leaflet with a view to producing a more engaging version that raises the profile of this important issue.” Source location 2019-0222-Response-by-Portsmouth-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish two continuity-of-carer pathway teams providing named midwives and buddies throughout antenatal, birth and postnatal care.
Verbatim wording from the response “As a first step towards achieving this, PHT is setting up 2 continuity of carer pathway teams, of 6-8 community midwives, each with midwife having a caseload of approximately 40 women. This will enable those women to have a named midwife and a “buddy” who will coordinate care throughout the antenatal, birth and postnatal period. The first team will be in place by the end of August with the second team being established towards the end of 2019.” Source location 2019-0222-Response-by-Portsmouth-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 Provide women with separate safe-sleeping information from the Child Health Record at discharge after birth.
Verbatim wording from the response “In the meantime, on discharge after birth, PHT midwives are giving women a separate photocopy of page 9 of the Child Health Record (red book) which contains advice about safe sleeping as well as details of the Lullaby Trust and NHS Choices where further advice can be obtained. This handheld book is normally given to women by their health visitor and not PHT midwives.” Source location 2019-0222-Response-by-Portsmouth-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 Handheld notes, scheduled checks and trained midwives are considered sufficient to identify and escalate pregnancy abnormalities despite lack of continuity.
Verbatim wording from the response “Nice Guidance “Antenatal care for uncomplicated pregnancies” CG62 sets out at Appendix D a schedule of appointments which should be provided for women with uncomplicated pregnancies. The requirement is for 10 appointments for nulliparous women and 7 for parous women. The schedule sets out in detail which checks and advice should be provided at each of the appointments. Each patient has their own hand held notes which are retained by them and brought to every antenatal appointment. As such each healthcare professional who meets a woman will have access to all the information they need to enable them to ensure that all necessary checks are performed and appropriate advice is shared with them.” Source location 2019-0222-Response-by-Portsmouth-Hospitals-NHS-Trust
Open published response
Concerns raised 12 Failure of the emergency information-relay system between birthing centres and hospitals View source Failure of midwives to acknowledge and actively consider requests for hospital transfer View source Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request View source Failure to create CTG equipment accounts for all authorised staff View source Poor technical quality of CTG readings during emergencies View source Vagueness of the Use of Standby Points policy for probing emergency requests View source Unclear classification of urgent, non-urgent and emergency transfers View source Failure of antenatal growth-risk assessment to include maternal BMI and emerging risk factors View source Lack of guidance for midwives on auscultation during transfer to hospital View source Lack of guidance for interpreting fetal heart-rate recovery after a bradycardic episode in labour View source Unavailability of CTG equipment in birthing centres View source Failure to record requests for transfer to hospital in clinical notes View source See 9 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
Rafe Robbie Angelo · 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
Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.
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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the emergency information-relay system between birthing centres and hospitals
Wider context from the report “This was a critical part of this case and as such needs further consideration of both the past and current systems and whether appropriate training has been given; whether it is currently working; and whether refresher training is needed .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of midwives to acknowledge and actively consider requests for hospital transfer
Wider context from the report “Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife . In this case, it was agreed by several witnesses including ████████ that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier decelerations.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled discretion by call handlers when time-critical factors are disclosed without an explicit time-critical transfer request
Wider context from the report “Discretion of SCAS call handlers if time critical factors are mentioned but birthing centre staff do not actually request a time critical transfer is requested.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create CTG equipment accounts for all authorised staff
Wider context from the report “Ensuring an account is created for all staff authorised to use CTG equipment so that settings and prints can be run
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor technical quality of CTG readings during emergencies
Wider context from the report “Poor technical quality of the CTG readings at a crucial time especially given this was the first time in an emergency situation
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Vagueness of the Use of Standby Points policy for probing emergency requests
Wider context from the report “The call to SCAS from the Blake lasted 4 minutes, 57 seconds and the fact the baby was in distress was not mentioned until 3 minutes, 53 seconds. The responding ambulance was dispatched at 15:46 and shortly afterwards the paramedic contacted control centre and indicated that it was appreciated the call was an emergency but could they use the facilities first. No questions were asked and permission was given ████████ accepted that if this had been designated as a time critical call, it may have made a difference as to whether permission to use facilities would have been given and asking questions or not would depend on the person taking the call from the paramedic. There was a policy to cover this sort of request – “Use of Standby Points” but it was accepted the policy is very broad and somewhat vague so it was accepted that it would very much depend on the person taking the call to probe further
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear classification of urgent, non-urgent and emergency transfers
Wider context from the report “The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required . That is why the maternity service has purchased handsets so that the midwife giving clinical care can contact SCAS directly rather than delegate the task. The request is now made in the birthing room so the mother can hear. In evidence, ████████ indicated that a transfer for epidural would be regarded as an emergency requiring an ambulance within one hour . This was different from ████████ who felt the transfer would be classified as non-urgent . A discussion took place in court as SCAS representatives believed the response times was 30 minutes (para 151).
This needs to be clarified between the Trust and SCAS and then clearly communicated to all staff.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of antenatal growth-risk assessment to include maternal BMI and emerging risk factors
Wider context from the report “The risk assessment of Ms Angelo followed NICE guidelines at the time but I remain concerned that no simple weigh check is done to check maternal BMI and that GROW charts only pick up 50-55% of cases where growth restriction occurs. A more holistic view is needed of risk factors especially in last few weeks from 34 weeks onwards as this is when the major growth spurt takes place and monitoring closely when additional factors surface is advisable e.g. as in this case cannabis and anti-depressant use were disclosed during this crucial period.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for midwives on auscultation during transfer to hospital
Wider context from the report “Guidance for midwives about auscultation practice during transfer to hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for interpreting fetal heart-rate recovery after a bradycardic episode in labour
Wider context from the report “After the bradycardic episode at 11:10 when the maternal position was changed, the recovery rate afterwards was higher than the previous baseline from 130-135 to 150+ thereafter. This was still within “normal” range but it was accepted during the inquest that this could be abnormal and no guidance currently exists .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of CTG equipment in birthing centres
Wider context from the report “CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record requests for transfer to hospital in clinical notes
Wider context from the report “Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife. In this case, it was agreed by several witnesses including ████████ that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier decelerations.
” Open source report
Concerns raised 1 Failure to email endoscopy discharge summaries to GP practices 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
Beryl Yvonne Foster · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Beryl Yvonne Foster underwent an endoscopic ultrasound examination on 8 December 2015, became unwell after discharge, was readmitted on 11 December 2015, and died on 2 January 2016. The concern was that posting, rather than emailing, the endoscopy discharge summary meant her GP practice was unaware of the procedure when she contacted it after becoming unwell, creating a risk in similar circumstances.
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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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to email endoscopy discharge summaries to GP practices
Wider context from the report “Mrs Foster's discharge summary was handed to her on 8 December 2015 and was subsequently posted to her GP practice. This meant that when she became unwell the following day and contacted the practice, it was unaware of the endoscopy the previous day . I was told that endoscopy discharge summaries are posted to GP practices by QAH, rather than emailed like all other discharge summaries . I am concerned this practice raises a risk that future deaths will occur in such circumstances and I would ask the NHS Trust to consider emailing all discharge summaries to GP practices in the future.
” Open source report
Concerns raised 1 Failure to implement consultants' requests for patient transfer to specialist wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Allen MacMORLAND · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Allen MacMORLAND was admitted to hospital with feeding difficulties and later readmitted with abdominal pain and distension; his condition deteriorated and he died on 5 December 2015. The substantive concern was that, despite five requests by consultant gastroenterologists, he was not transferred to a specialist gastroenterology ward, and evidence indicated that such a ward might have affected the outcome.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement consultants' requests for patient transfer to specialist wards
Wider context from the report “I was told in evidence at the Inquest that despite Mr MacMORLAND being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward - even though the consultants had during that time requested such a transfer on five separate occasions . Given the nature of his medical problems, from the evidence I heard, I am of the opinion that he could have benefited from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome. I was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.
Verbatim wording from the response “By way of further assurance, since this death in 2015, the Hospital has begun a ‘buddy’ ward system whereby patients of a certain specialty are cohorted only into the appropriate specialist ward or a specific buddy ward. This means that consultants will have their patients only on one other ward if their own base ward is full.” Source location 2016-0415-Response-by-Portsmouth-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 Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.
Verbatim wording from the response “The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon. The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised.” Source location 2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Open published response
Concerns raised 6 Failure to account for current INR and intervening treatments when restarting warfarin View source Failure to ensure that junior doctors and nurse practitioners are aware of the relevant anticoagulation protocol View source Failure to obtain a requested INR test to establish current INR levels and inform further treatment View source Lack of clarity about when to restart normal warfarin treatment View source Lack of clarity about responsibility for anticoagulation clinical decisions View source Lack of clarity about when to reverse the anticoagulation protocol 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.
×
AI-generated summary
Michael Blow · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Blow was admitted after falling downstairs and sustained chest injuries, including fractured ribs, lung contusions and a pneumothorax. His condition later deteriorated, with blood in the chest drain, an INR of 9, and he died following cardiac arrest; the recorded cause of death included haemothorax, fractured ribs and warfarin treatment. Concerns included a requested INR test not being carried out and warfarin being restarted using an outdated INR result without sufficient account of other treatments and medication.
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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for current INR and intervening treatments when restarting warfarin
Wider context from the report “2. Warfarin was restarted after ████████ review but was based on an outdated INR reading of 5.5 taken on admission and no account was taken of the Octaplex and blood transfusion plus any other medication such as 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that junior doctors and nurse practitioners are aware of the relevant anticoagulation protocol
Wider context from the report “3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol; who is responsible for this sort of clinical decision; and, importantly when to restart normal warfarin treatment.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain a requested INR test to establish current INR levels and inform further treatment
Wider context from the report “1. The INR test requested by ████████ during the morning of Saturday 27th was never carried out despite being a basic check to baseline Mr Blow’s INR levels and see what effect the Octaplex and blood transfusion plus any antibiotic treatment since admission may have had on his reading to inform further treatment.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to restart normal warfarin treatment
Wider context from the report “3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol; who is responsible for this sort of clinical decision; and, importantly when to restart normal warfarin treatment .
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for anticoagulation clinical decisions
Wider context from the report “3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol; who is responsible for this sort of clinical decision ; and, importantly when to restart normal warfarin treatment.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to reverse the anticoagulation protocol
Wider context from the report “3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol ; who is responsible for this sort of clinical decision; and, importantly when to restart normal warfarin treatment.
” Open source report
Concerns raised 2 Delays in typing fracture clinic doctors' notes causing their unavailability when out-patients return View source Failure to re-assess relevant fracture clinic out-patients under the DVT assessment policy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Anthony Mayoll · 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
Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury, for which he received outpatient treatment at Queen Alexandra Hospital between 11 and 20 June 2013. He became very unwell at home on 21 June and died in hospital at 03.20 hours on 22 June 2013 from a pulmonary thromboembolism arising from a deep vein thrombosis. Concerns included the lack of reassessment under the hospital’s DVT assessment policy for similar fracture-clinic outpatients and delays in making fracture-clinic doctors’ notes available.
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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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in typing fracture clinic doctors' notes causing their unavailability when out-patients return
Wider context from the report “2- Evidence was given at the Inquest highlighting the delay in typing fracture clinic doctors' notes meaning that they would not always be available if an out-patient returned to the clinic and improved methods of making the notes available sooner to the clinic (e.g. by use of voice recognition IT) would obviate this problem.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to re-assess relevant fracture clinic out-patients under the DVT assessment policy
Wider context from the report “1- Out-patients with similar injuries to Mr Mayoll's returning to the fracture clinic at Queen Alexandra Hospital experiencing problems with their treatment or for periodic review are not subject to re-assessment under the hospital's DVT assessment policy . If they were, there would be less risk of their developing DVT's during the course of their treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the plaster-room “in trouble” form to document venous thromboembolism assessment recommendations.
Verbatim wording from the response “1. Patients who return to the fracture clinic with lower limb injuries as “in trouble” or for routine review, will have a reassessment of their risk factors for VTE each time they attended, the result of which will be considered by the doctor reviewing them. This will be documented via the normal route on a plaster room “in trouble” form which is currently being updated and will include the recommendations from the Inquiry relating to VTE assessment.” Source location 2014-0515-Response-by-Portsmouth-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 Reassess venous thromboembolism risk factors at every fracture-clinic return for patients with lower-limb injuries.
Verbatim wording from the response “1. Patients who return to the fracture clinic with lower limb injuries as “in trouble” or for routine review, will have a reassessment of their risk factors for VTE each time they attended, the result of which will be considered by the doctor reviewing them. This will be documented via the normal route on a plaster room “in trouble” form which is currently being updated and will include the recommendations from the Inquiry relating to VTE assessment.” Source location 2014-0515-Response-by-Portsmouth-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 Explore information-technology solutions to improve the availability of consultant review notes.
Verbatim wording from the response “2b. An “in trouble” patient reviewed by the Consultant will have the notes dictated that day and then typed up by the Orthopaedic secretaries with the aim for them to be typed within 24-hours. We are exploring IT solutions as well but this is the interim solution. The current EPRO system (a digital dictation system) involves the notes being typed up by agency staff and, possibly, in the future, outside agencies and it is anticipated that the normal typing turnaround will be at 48-hours by the end of March which is still not quick enough to ensure that information is available for a Consultant reviewing a returning patient. However, there is the ability through EPRO to gain access to the tapes but the Consultants can listen to the recording if the typed notes are not available. This is being fed back at the next consultants’ meeting, by way of reminder.” Source location 2014-0515-Response-by-Portsmouth-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dictate consultant notes on the day of review and type them through Orthopaedic secretaries within 24 hours.
Verbatim wording from the response “2b. An “in trouble” patient reviewed by the Consultant will have the notes dictated that day and then typed up by the Orthopaedic secretaries with the aim for them to be typed within 24-hours. We are exploring IT solutions as well but this is the interim solution. The current EPRO system (a digital dictation system) involves the notes being typed up by agency staff and, possibly, in the future, outside agencies and it is anticipated that the normal typing turnaround will be at 48-hours by the end of March which is still not quick enough to ensure that information is available for a Consultant reviewing a returning patient. However, there is the ability through EPRO to gain access to the tapes but the Consultants can listen to the recording if the typed notes are not available. This is being fed back at the next consultants’ meeting, by way of reminder.” Source location 2014-0515-Response-by-Portsmouth-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 Remind consultants at their next meeting about accessing dictated recordings when typed notes are unavailable.
Verbatim wording from the response “2b. An “in trouble” patient reviewed by the Consultant will have the notes dictated that day and then typed up by the Orthopaedic secretaries with the aim for them to be typed within 24-hours. We are exploring IT solutions as well but this is the interim solution. The current EPRO system (a digital dictation system) involves the notes being typed up by agency staff and, possibly, in the future, outside agencies and it is anticipated that the normal typing turnaround will be at 48-hours by the end of March which is still not quick enough to ensure that information is available for a Consultant reviewing a returning patient. However, there is the ability through EPRO to gain access to the tapes but the Consultants can listen to the recording if the typed notes are not available. This is being fed back at the next consultants’ meeting, by way of reminder.” Source location 2014-0515-Response-by-Portsmouth-Hospitals-NHS-Trust
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Concerns raised 2 Failure to issue correct Clonodine prescriptions View source Failure to communicate and coordinate timely Clonodine supply 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
Courtney Jordan Mills · 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
Courtney Jordan Mills was found unresponsive in bed at home on 19 April 2013 and was pronounced deceased at hospital that morning. The concerns included repeated prescription and communication problems affecting access to Clonodine, which was reported as a medication that should not be stopped abruptly, and the potential risk to other children in similar circumstances. The inquest recorded acute bronchopneumonia in a child with sleep apnoea and cerebral palsy, with death due to natural causes.
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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to issue correct Clonodine prescriptions
Wider context from the report “I was told that (quote):
"Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs."
I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances.
” 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 Portsmouth Hospitals University NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and coordinate timely Clonodine supply
Wider context from the report “I was told that (quote):
"Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs."
I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances.
” Open source report
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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 If medication-continuity issues require national consideration, the Royal Pharmaceutical Society is suggested as the appropriate body to address them.
Verbatim wording from the response “I am aware that maintaining correct medication when patients leave hospital is a significant problem across the NHS as it involves co-ordination between hospitals, GP practices, pharmacy and patients themselves, often with an important medication change made as a result of acute illness. While doctors clearly share responsibility for this, Pharmacists may be best placed to ensure safe processes around this. In the first instance, and if you feel that this issue needs to be considered on a national level, I would suggest that the Royal Pharmaceutical Society may be the best body to contact.” Source location 2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing assessment-unit and pharmacy arrangements would have enabled medication supply if the hospital had been approached, so no further Trust steps were proposed.
Verbatim wording from the response “I understand from ████████ that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient’s family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription.” Source location 2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The medication was not prescribed by the Trust, and there was no evidence that the hospital had been approached for a supply.
Verbatim wording from the response “I understand from ████████ that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient’s family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription.” Source location 2014-0224-Response-by-Portsmouth-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