Recipient

Recipient name withheld

First report 22 Jan 2024•Latest report 22 Jan 2024

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

22 Jan2024
Teesside and Hartlepool
Concerns raised12
1. Inaccurate recording of clinical communications in case notes
2. Failure to physically assess the patient by a doctor before discharge
3. Inadequate nursing documentation of vomiting, pain and pain scores
1. Failure to respond to reported pain with pain relief or medical escalation
2. Lack of consultant urologist knowledge of surgery classification and SIGN guidelines
3. Incorrect prescribing of prophylactic antibiotics after urology surgery
4. Failure to provide families with deterioration warning signs and actions at discharge
5. Failure to recognise the recommendation for prophylactic antibiotics in gastro-intestinal surgery
6. Failure to provide prophylactic antibiotics for gastro-intestinal surgery
7. Failure of operation planning to ensure colorectal surgeon attendance
8. Insufficient vigilance and recognition of post-operative presentation
9. Failure to review pre-surgery urine test results
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

Kate Elizabeth O’Donnell · 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

Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate recording of clinical communications in case notes
Wider context from the report
“8. Case notes included details of a meeting on 14.03.22 which did not taken place and was a telephone call. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to physically assess the patient by a doctor before discharge
Wider context from the report
“6. Kate was not physically assessed by a doctor prior to discharge. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Inadequate nursing documentation of vomiting, pain and pain scores
Wider context from the report
“7. The nursing notes did not include relevant information, to include Kate vomiting and that she was in pain. The pain scores were understated. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to respond to reported pain with pain relief or medical escalation
Wider context from the report
“9. The nursing team did not respond to repeated statements that Kate was in pain-she was not offered pain relief nor was medical help sought. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Lack of consultant urologist knowledge of surgery classification and SIGN guidelines
Wider context from the report
“3. The consultant urologist was not aware of the classification of surgeries and didn’t know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for this type of gastro-intestinal surgery. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Incorrect prescribing of prophylactic antibiotics after urology surgery
Wider context from the report
“2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide families with deterioration warning signs and actions at discharge
Wider context from the report
“10. The family were not provided with information upon discharge as to what signs to look out for and what steps to take if Kate was to deteriorate. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise the recommendation for prophylactic antibiotics in gastro-intestinal surgery
Wider context from the report
“3. The consultant urologist was not aware of the classification of surgeries and didn’t know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for this type of gastro-intestinal surgery. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide prophylactic antibiotics for gastro-intestinal surgery
Wider context from the report
“4. The consultant urologist overlooked the provision of prophylactic antibiotics for the gastro-intestinal surgery. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure of operation planning to ensure colorectal surgeon attendance
Wider context from the report
“1. Planning for the operation was poor and resulted in the non-attendance of a colorectal surgeon at the surgery. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Insufficient vigilance and recognition of post-operative presentation
Wider context from the report
“5. There was insufficient vigilance and recognition given to Kate’s post-operative presentation, considering Kate’s vulnerabilities, comorbidities, and extensive past involvement with the medical teams. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to review pre-surgery urine test results
Wider context from the report
“2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised12

Inaccurate recording of clinical communications in case notes

Failure to physically assess the patient by a doctor before discharge

Inadequate nursing documentation of vomiting, pain and pain scores

Failure to respond to reported pain with pain relief or medical escalation

Lack of consultant urologist knowledge of surgery classification and SIGN guidelines

Incorrect prescribing of prophylactic antibiotics after urology surgery

Failure to provide families with deterioration warning signs and actions at discharge

Failure to recognise the recommendation for prophylactic antibiotics in gastro-intestinal surgery

Failure to provide prophylactic antibiotics for gastro-intestinal surgery

Failure of operation planning to ensure colorectal surgeon attendance

Insufficient vigilance and recognition of post-operative presentation

Failure to review pre-surgery urine test results