Recipient

Queen's Hospital, Burton

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First report 16 Dec 2013•Latest report 30 May 2019

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
4

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Queen's Hospital, Burton linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Geoffrey Duke · 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

    Geoffrey Duke became unwell repeatedly after a pacemaker box change in June 2016 and was later found to have infection involving the pacemaker wires. The principal concerns were that the pacemaker was not considered as a possible source of infection, no cardiology referral was made, and there was no evidence of a referral process for patients who became unwell after pacemaker surgery. He died in hospital on 20 December 2017 after deterioration during treatment and surgery.

    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 Queen's Hospital, Burton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider pacemaker box change as a potential source of infection

    Wider context from the report

    “Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell. ”
    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 Queen's Hospital, Burton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a referral process for patients who become unwell after pacemaker surgery

    Wider context from the report

    “Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell. ”
    Open source report

  2. Staffordshire South

    AI-generated summary

    Norma Doris Sheppard · 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

    Norma Doris Sheppard fell in her care home, broke her right hip, underwent surgical repair, later suffered a stroke affecting her swallowing, and died on 10 April 2013 from the effects of the fall. There was considerable confusion about whether she was to receive subcutaneous fluids after discharge from hospital to a care home, contrary to the written discharge document.

    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 Queen's Hospital, Burton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure clear and consistent discharge instructions

    Wider context from the report

    “There was considerable confusion about the terms of Mrs Sheppard’s discharge from Queens Hospital to the care home on 25 March 2013. There was a written discharge letter that indicated that Mrs Sheppard should continue to receive sub cutaneous fluids at the care home and this presented considerable difficulties in finding somewhere suitable to take her. In fact when she was discharged it appears to be on an understanding that she was not going to receive sub cutaneous fluids although this was contrary to the discharge document. ”
    Open source report

  3. Staffordshire South

    AI-generated summary

    Ronald Sidney Ellwood · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Ellwood died from a chest infection after spending several weeks in the intensive care unit at Queen’s Hospital. Concerns were raised about bugs associated with invasive tubes and about heat, ventilation and the possible benefit of more fresh air in the intensive care unit.

    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 Queen's Hospital, Burton; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of fresh air in intensive care units

    Wider context from the report

    “Mr Ellwood died as the result of a chest infection. He had spent several weeks in the intensive care unit (ICU) at Queen’s Hospital and I heard helpful evidence from ████████ Clinical Lead for Critical Care about the number of bugs that those invasive tubes are subject to and the need to treat the bugs that may be causing harm. Mr Ellwood’s widow referred to the heat and a lack of fresh air in the ICY. ████████ indicated that the ICU did have air conditioning but he was sympathetic to the suggestion of more fresh air although this was an estates issue. This may have been considered in the past but I wonder if it may be to the benefit rather than detriment of patients in intensive care to have more fresh air (through opened windows) as opposed to recycled air through air conditioning? ”
    Open source report

  4. Staffordshire South

    AI-generated summary

    Elsie May Treece · 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

    Elsie May Treece died in hospital on 2 August 2013 after falls at her care home, including a fall that caused a broken arm and an inoperable brain bleed. Concerns included an alleged incident during her hospital care that may not have been reported and the absence of a CT scan after her earlier hospital attendance.

    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 Queen's Hospital, Burton; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report inappropriate patient-handling incidents

    Wider context from the report

    “(1) I received information from the family that on the afternoon of the 26 July 2013, following difficulties in moving Mrs Treece, for a while hospital staff left one of Mrs Treece’s daughters (aged 70) supporting her mother. One of them then returned with a blue lifting bag with handles but she was not properly supported and fell back heavily on the bed with some force. Investigation has been carried out by ████████ the Ward 6 manager and I received a report which indicates there is no record of any such incident either in paper records, electronic records or from speaking to staff on duty. I did not investigate this incident fully because on balance it is unlikely to have been significant so far as the death is concerned. However the view I took on the evidence I did hear was that there had been an incident which should have been reported and may well not have been. I therefore write to you to enquire if staff need to be reminded or may need further training regarding the requirement to report inappropriate incidents even if no major harm seems to come to the patient involved. (2) While writing to you perhaps you could also find out for me the reasons why Mrs Treece did not have a CT scan of her head following the attendance on the 18 July 2013. This is not strictly a matter for this formal report but an answer would be appreciated. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026