27 Oct 2025 Louisa Walker · Prevention of Future Deaths report Berkshire
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Concerns raised 1 Failure of obstetricians to undergo incident-derived training View source
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AI-generated summary
Louisa Walker · 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
Louisa Walker’s head was impacted in her mother’s pelvis during a caesarean section, and she suffered skull fractures and intracranial bleeding during manoeuvres to disimpact her head. She was born on 25 May 2024 and died on 28 June 2024. The principal concern was that, despite an action plan for training arising from the incident, 83% of the trust’s obstetricians had not undergone that training by the inquest.
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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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of obstetricians to undergo incident-derived training
Wider context from the report “1. If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training . For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue , provided before Louisa’s death.
” Open source report
13 Feb 2024 Michael James NYE · Prevention of Future Deaths report Berkshire
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Concerns raised 7 Delays in completion of night-time blood tests View source Lack of effective night-time Internal Escalation Policy measures View source Delays in notification of abnormal blood test results to clinicians View source Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate View source Lack of contemporaneous record keeping in the Emergency Department View source Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call View source Burdensome and time-consuming out-of-hours CT scan requesting system View source See 4 more concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Michael James NYE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael James Nye attended the Royal Berkshire Hospital with sepsis caused by a Streptococcus A skin and soft tissue infection, but was initially diagnosed with an upper arm DVT. His condition deteriorated and he suffered two cardiac arrests, with his death verified on 15 November 2022. Concerns included delays in blood tests, CT scanning, escalation to the Intensive Care Unit and prescribing antibiotics, as well as overcrowding, inadequate escalation arrangements and training needs concerning atypical sepsis.
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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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in completion of night-time blood tests
Wider context from the report “a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed.
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of effective night-time Internal Escalation Policy measures
Wider context from the report “d. The lack of a specific night time Internal Escalation Policy . A number of the general Internal Escalation Policy measures are not effective at night ;
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in notification of abnormal blood test results to clinicians
Wider context from the report “a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed .
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate
Wider context from the report “f. The need for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate .
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of contemporaneous record keeping in the Emergency Department
Wider context from the report “c. The lack of contemporaneous record keeping in the Emergency Department ;
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call
Wider context from the report “e. The need for training of all Intensive Care Unit clinicians at all levels, both existing Intensive Care Unit clinicians and new joiners, in the policy that a "just to let you know" call should result in an Intensive Care review of the patient ;
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Burdensome and time-consuming out-of-hours CT scan requesting system
Wider context from the report “b. The burdensome and time consuming out of hours system for clinicians requesting CT scans from an external provider ;
” Open source report
28 Nov 2018 Michelle Roach · Prevention of Future Deaths report Berkshire
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Concerns raised 6 Lack of knowledge of the signs and symptoms of venous thromboembolism View source Insufficient medical registrar cover at night View source Deficient GP record-keeping practices View source Insufficient clinical knowledge of unexpected deaths and related clinical management View source Failure of the GP practice system to investigate unexpected deaths View source Deficient GP record keeping View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michelle Roach · 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
Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.
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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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the signs and symptoms of venous thromboembolism
Wider context from the report “(1) I believe ████████ should consider reviewing and updating her knowledge in relation to the signs and symptoms of venous thromboembolism .
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical registrar cover at night
Wider context from the report “(1) I consider that the trust should review its level of cover by medical registrars at night . Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust.
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Deficient GP record-keeping practices
Wider context from the report “(2) I believe ████████ should review her record-keeping practices .
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of unexpected deaths and related clinical management
Wider context from the report “(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping.
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the GP practice system to investigate unexpected deaths
Wider context from the report “(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping.
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Deficient GP record keeping
Wider context from the report “(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping .
” Open source report
Concerns raised 1 Failure to maintain an evidence-aligned policy for perioperative blood glucose levels 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
Mr Michael Quinn · 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 Michael Quinn underwent lumbar decompression surgery and was discharged home, but subsequently developed diarrhoea and vomiting, was admitted critically ill, and died despite intensive treatment. The principal concern was confusion and inconsistency about appropriate perioperative blood glucose levels for patients undergoing surgery, including a written policy that did not align with national guidelines and other published research.
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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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an evidence-aligned policy for perioperative blood glucose levels
Wider context from the report “(2) It is clear to me that there is a great deal of confusion about what is an appropriate level for patients such as Mr Quinn and the optimal blood glucose level that should be achieved in patients, diabetic or otherwise, prior to surgery . While I did not find at the Inquest that Mr Quinn’s blood glucose level of 13mmol was a factor in the infection that led to his death, I am nevertheless concerned that the written policy in place at the time does not mirror that of the national guidelines and is also at odds with other published research articles .
(3) I am directing this report to you because I understand that the method adopted by Circle Hospital was based on the policy of your Trust which took the lead in these matters.
” Open source report
Concerns raised 2 Failure to highlight the cot-side locking problem in all trolley maintenance schedules View source Failure to escalate and notify trolley users of the known cot-side locking risk 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
James Wilson Fyfe · 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
James Wilson Fyfe died on 21 April 2011 from pneumonia significantly contributed to by a cervical spine fracture sustained when he fell from a hospital trolley after its cot side gave way. Concerns related to the trolley remaining raised but unlocked due to design, maintenance and use issues, and to uncertainty about whether the known hazard had been communicated to other users of the trolley.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight the cot-side locking problem in all trolley maintenance schedules
Wider context from the report “(1) It was the Jury’s determination on the evidence that the cot side was able to remain in a raised but unlocked position due in part to both the design and maintenance of the trolley. While evidence was given that the Trust had subsequently introduced improved service sheets and had involved the assistance of Anetic Aid Limited in maintenance, repair and training of use of the trolley, it was unclear as to whether this specific problem had been highlighted as needing careful attention in all maintenance schedules for the trolley .
” 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 Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and notify trolley users of the known cot-side locking risk
Wider context from the report “(2) The Jury were informed that MHRA were aware of the investigations of the incident trolley but that it did not appear that the issue had been escalated and notified to all Hospital Trusts and agencies that used this type of trolley . The MHRA’s actions in being informed of this potential hazard remain unclear, with particular reference to passing on the known risk to such trolley users .
” 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