Royal Albert Edward InfirmaryIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 16 Jun 2017•Latest report 16 Jun 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Royal Albert Edward Infirmary linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Clinical Director, Royal Albert Edward Infirmary.

    Manchester West

    AI-generated summary

    Katherine Anne Derbyshire · 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

    Katherine Anne Derbyshire, who had end stage chronic kidney disease, was admitted on 12 November 2016 after compromised dialysis function and a presumed blockage and infection of her peritoneal catheter. She deteriorated while awaiting transfer for ongoing dialysis, became unfit for transfer, and died on 21 November 2016 after palliative end-of-life medication was prescribed. The concerns included the failure to transfer her, delays in considering temporary dialysis, and inadequate communication and contingency planning between the two hospitals.

    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 Royal Albert Edward Infirmary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to triage clinical needs to effect timely transfer

    Wider context from the report

    “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:- a. No transfer to Salford Royal Infirmary, in fact, took place; b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary; c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case; 2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that: a. This possible alternative was not considered earlier; b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care; c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016. d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient; 3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and 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 Royal Albert Edward Infirmary; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication between hospitals about dialysis transfer and bed availability

    Wider context from the report

    “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:- a. No transfer to Salford Royal Infirmary, in fact, took place; b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary; c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case; 2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that: a. This possible alternative was not considered earlier; b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care; c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016. d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient; 3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and 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 Royal Albert Edward Infirmary; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in considering alternative temporary dialysis

    Wider context from the report

    “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:- a. No transfer to Salford Royal Infirmary, in fact, took place; b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary; c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case; 2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that: a. This possible alternative was not considered earlier; b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care; c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016. d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient; 3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and 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 Royal Albert Edward Infirmary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to transfer patients requiring ongoing dialysis treatment and care

    Wider context from the report

    “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:- a. No transfer to Salford Royal Infirmary, in fact, took place; b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary; c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case; 2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that: a. This possible alternative was not considered earlier; b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care; c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016. d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient; 3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and 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 Royal Albert Edward Infirmary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of dialysis treatment and care plans to provide for patient deterioration

    Wider context from the report

    “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:- a. No transfer to Salford Royal Infirmary, in fact, took place; b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary; c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case; 2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that: a. This possible alternative was not considered earlier; b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care; c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016. d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient; 3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care. ”
    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

Data last updated 7 September 2026