27 Nov 2023 Jennifer Ruth Whinney · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of assigned responsibility for ensuring that patient notes are sent to external appointments View source Failure to ensure that patient notes accompany external appointments View source Poor maintenance of PICC lines 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
Jennifer Ruth Whinney · 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
Jennifer Ruth Whinney developed recurrent infections in her PICC lines after being admitted to the Royal London Hospital for bowel surgery, leading to septicaemia and multi-organ failure. She died following surgery to repair a bowel fistula. The report raised concern that her medical records were not sent to a specialist appointment and that there was no individual responsibility for ensuring records accompanied patients, risking important information not being passed on.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Lack of assigned responsibility for ensuring that patient notes are sent to external appointments
Wider context from the report “Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent.
Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that patient notes accompany external appointments
Wider context from the report “Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent.
Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Poor maintenance of PICC lines
Wider context from the report “Whilst at the Royal London Hospital Jennifer had at least 6 episodes of sepsis from infected PICC lines. I heard evidence that these infections were contributed to by poor PICC line maintenance . and that the consultant colorectal surgeon raised concerns about the number of PICC line infections that Jennifer and other patients on the ward were getting . I heard some evidence about steps that had been taken but I was told that it was a nursing issue and I only heard evidence from a surgeon. I did not receive any written evidence about changes that have been made.
” Open source report
14 Oct 2021 Louie Neil Johnston · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to ensure medical staff complete mandated annual CTG training View source Failure of CTG monitoring equipment to keep the CTG trace clearly visible during delivery 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
Louie Neil Johnston · 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
Louie Neil Johnston died in hospital on 28 April 2020 from diffuse hypoxic ischaemic encephalopathy caused by inadequate oxygen supply to his brain during delivery. The report identified avoidable delivery delays, limitations in CTG monitoring equipment, and gaps in mandatory CTG training for staff.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical staff complete mandated annual CTG training
Wider context from the report “2. A review of staff training records indicated that an obstetric registrar involved in the delivery was not up to date with mandated annual CTG training . Additionally, the obstetric consultant had not completed annual training which required the session to be repeated following the death of Louie Johnston. Systems in place at the Trust did not ensure that all medical staff had completed requisite training .
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure of CTG monitoring equipment to keep the CTG trace clearly visible during delivery
Wider context from the report “1. CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery . This meant that a graphic representation of the CTG trace was not clearly visible at all times . Instead, midwifery staff were required to crouch down and record numeric data from the CTG displayed on a small LED screen. The Trust identified this as counter-productive and raised the issue with the manufacturer of the system. To date, the system has not been updated .
” Open source report
12 Oct 2021 Mrs Vivien Brunning · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Omissions of prescribed daily low molecular weight heparin injections View source Failure to report noticed medication omissions through the incident reporting system View source Failure to undertake required venous thromboembolism reviews at 24 and 72 hours following admission 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
Mrs Vivien Brunning · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Vivien Brunning was admitted to hospital with sepsis and treated for a kidney stone, during which prescribed Clexane was temporarily held and then omitted on 13 and 14 July 2020. She developed a right brachial artery thrombosis, suffered a stroke during emergency thrombolysis, and died on 25 July 2020. Concerns included missed venous thromboembolism reviews, omitted anticoagulant doses, and failure to report the initial omission through the Trust’s incident reporting system.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Omissions of prescribed daily low molecular weight heparin injections
Wider context from the report “2. Prescribed daily injections of low molecular weight heparin were omitted on 13th and 14th July 2020
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to report noticed medication omissions through the incident reporting system
Wider context from the report “3. The initial omission on 13th July 2020 was noticed by a ward doctor but was not reported through the Trust’s incident reporting system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Queen's Hospital, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required venous thromboembolism reviews at 24 and 72 hours following admission
Wider context from the report “1. The hospital notes demonstrate that required venous thromboembolism reviews at 24 & 72 hrs following admission were not undertaken .
” Open source report
18 May 2021 Juliet Saunders · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Serious Incident Investigation process failing to identify significant care failings and produce a good-quality report View source Poor medical record keeping and documentation in the emergency department and observation unit View source Failure to recognise abnormal findings on abdominal radiographs View source Failure of systems to provide supervision and escalation of complex cases involving junior doctors View source Absence of emergency department staff support for patients with learning disability during weekends View source Lack of clinical curiosity and failure to reconsider a queried diagnosis when findings are inconsistent View source Absence of safety-netting advice for patients leaving the hospital View source Departure from established procedures for safe transfers from the emergency department to the observation unit View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Juliet Saunders · 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
Juliet Saunders, a 25-year-old woman with Cornelia De Lange Syndrome and a profound learning disability, attended hospital on 7 March 2020 with abdominal pain and vomiting and died at home the following day. The report identified concerns including misinterpretation of abdominal x-rays, failure to diagnose intestinal obstruction, inadequate escalation and supervision, departures from transfer and discharge procedures, lack of safety-netting advice, and insufficient support for patients with learning disabilities at weekends.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Serious Incident Investigation process failing to identify significant care failings and produce a good-quality report
Wider context from the report “8. Ineffective identification of significant failings in care delivered through the Trust’s own Serious Incident Investigation process , leading to a finalised report of poor quality.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Poor medical record keeping and documentation in the emergency department and observation unit
Wider context from the report “2. The poor standard of medical record keeping and documentation within the emergency department and observation unit.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise abnormal findings on abdominal radiographs
Wider context from the report “4. Consecutive failures by medical and radiological staff to recognise abnormal findings within an abdominal radiograph , impacted upon by diagnostic overshadowing.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to provide supervision and escalation of complex cases involving junior doctors
Wider context from the report “3. The failure of systems within the department to allow for the supervision of junior doctors to ensure that complex cases are escalated to more experienced 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 Queen's Hospital, Romford; that does not assign responsibility.
PFD Monitor interpretation Absence of emergency department staff support for patients with learning disability during weekends
Wider context from the report “1. The absence of any support for staff within the emergency department during weekends, in dealing with patients with learning disability.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical curiosity and failure to reconsider a queried diagnosis when findings are inconsistent
Wider context from the report “5. A lack of clinical curiosity, combined with diagnostic overshadowing meant that there was a reluctance to depart from a queried diagnosis of gastritis which led to the failure to diagnose an acute intestinal obstruction.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Absence of safety-netting advice for patients leaving the hospital
Wider context from the report “7. The absence of safety-netting advice to patients leaving the 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 Queen's Hospital, Romford; that does not assign responsibility.
PFD Monitor interpretation Departure from established procedures for safe transfers from the emergency department to the observation unit
Wider context from the report “6. A departure from established procedures to ensure the safety of transfers out of the emergency department to the observation unit.
” Open source report
6 Nov 2020 Stanley Alfred Babbs · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to identify a responsible clinician for contrast administration View source Administration of contrast media without a formal prescription View source Lack of careful consideration of contrast medium dose View source Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stanley Alfred Babbs · 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
Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a responsible clinician for contrast administration
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it .
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Administration of contrast media without a formal prescription
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast . This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription , evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Lack of careful consideration of contrast medium dose
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight .
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Open source report
28 Jan 2015 Iana-Liza Chervonenko · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 7 Absence of a system for proactively notifying the treating team when theatre becomes available View source Failure to conduct fully informed and thorough discussions with colleagues about prioritisation View source Delays in obtaining timely medical review of concerning or pathological CTG traces View source Failure to clearly and accurately document clinical reviews, decisions and caesarean-section grading View source Failure to conduct fully informed discussions with anaesthetists about the required type of anaesthesia View source Deficient communication between the medical and midwifery teams View source Insufficient medical cover on the labour ward View source See 4 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
Iana-Liza Chervonenko · 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
Iana-Liza Chervonenko was delivered by emergency caesarean section after delays associated with a pathological CTG, heavy workload, poor communication and clinical decision-making on the labour ward. She was born at 02.30 with no heart rate or spontaneous respiration and died at twenty-four hours of age from hypoxic-ischaemic encephalopathy caused by intra-partum asphyxia. Concerns included inadequate medical cover, deficient documentation and communication, and the absence of a system to notify the treating team when theatre became available.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Absence of a system for proactively notifying the treating team when theatre becomes available
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available . I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct fully informed and thorough discussions with colleagues about prioritisation
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation ; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining timely medical review of concerning or pathological CTG traces
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly and accurately document clinical reviews, decisions and caesarean-section grading
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions ; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct fully informed discussions with anaesthetists about the required type of anaesthesia
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Deficient communication between the medical and midwifery teams
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team . The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” 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, Romford; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical cover on the labour ward
Wider context from the report “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following:
• A delay in obtaining a medical review to the concerning CTG trace.
• A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace.
• Incorrect documentation in relation to the grading of the caesarean section.
• Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient.
• The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients.
2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40.
The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40.
Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40.
I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation.
I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest.
” Open source report
19 Sep 2013 Tripta Rani KUMAR · Prevention of Future Deaths report London Eastern
View report summary
Concerns raised 2 Failure to prevent prescribing penicillin-type antibiotics to patients with penicillin allergy View source Failure to maintain accurate and attributable penicillin allergy records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Tripta Rani KUMAR · 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
Tripta Rani KUMAR underwent planned hysterectomy and was discharged, but was readmitted the following day with abdominal pain and a perforated bowel. She developed sepsis, suffered a cardiac arrest on 25 August 2012, and died despite CPR. A principal concern was that penicillin-containing Tazocin was prescribed despite records and a wristband indicating a penicillin allergy, after an unsigned handwritten alteration changed the record to “nil allergies”.
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, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent prescribing penicillin-type antibiotics to patients with penicillin allergy
Wider context from the report “In the emergency department, during the course of treatment given on the 24th August 2012, the deceased was attended to by an ST4, doctor in Obstetrics and Gynaecology. The doctor documented the likely diagnosis, requested an urgent CT scan and prescribed intravenous antibiotics in the form of Tazocin . Tazocin contains two active ingredients, Piperacillin, which is a penicillin type antibiotic and Tazobactum which is a medicine that prevents bacteria from inactivating Piperacillin.
Evidence from the family of the deceased, confirmed by ████████ (Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. ████████ further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead. This was in handwriting but with no signature to confirm who had written the note.
The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in an anaphylactic shock which, in turn, could have resulted in death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Queen's Hospital, Romford; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and attributable penicillin allergy records
Wider context from the report “In the emergency department, during the course of treatment given on the 24th August 2012, the deceased was attended to by an ST4, doctor in Obstetrics and Gynaecology. The doctor documented the likely diagnosis, requested an urgent CT scan and prescribed intravenous antibiotics in the form of Tazocin. Tazocin contains two active ingredients, Piperacillin, which is a penicillin type antibiotic and Tazobactum which is a medicine that prevents bacteria from inactivating Piperacillin.
Evidence from the family of the deceased, confirmed by ████████ (Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. ████████ further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead . This was in handwriting but with no signature to confirm who had written the note .
The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in an anaphylactic shock which, in turn, could have resulted in death.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations