20 Nov 2024 Charlotte Ann ROSCOE · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to liaise with radiology when a preferred scan type requires discussion View source Failure to submit specific scan requests using the correct form and rationale View source Failure to establish whether VQ or CTPA is the appropriate scan modality for suspected pulmonary embolism 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
Charlotte Ann ROSCOE · 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
Charlotte Ann ROSCOE attended hospital with chest pains and was discharged after a VQ scan found no pulmonary embolism. She was found deceased at home the following day; post-mortem examination identified haemopericardium caused by rupture and dissection of the ascending aorta. Concerns included the missed opportunity to detect the aortic dissection by CT, reliance on outdated observations at discharge, and unclear processes for specifying and communicating scan requests with radiology.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with radiology when a preferred scan type requires discussion
Wider context from the report “2. Evidence was received from a doctor who referred the deceased for a scan, that she had thought she had requested a CTPA to be undertaken, but the form that was used was a request for an “acute pulmonary embolus investigation” which meant that the request would be vetted and an appropriate mode of scan arranged following consideration by a radiologist. It was stated by the doctor that it would not be normal to speak to radiology regarding a request for a scan.
3. In evidence from a radiologist it was stated that a medical clinician would be expected to speak to a radiologist if there was any preference for a type of scan to be undertaken so this could be discussed. It appeared to me that the use of the correct form, need to be specific, provide rationale for a specific type of scan request, and liaising with radiology as appropriate was not appreciated in this case. As above, given that there was no radiographer involved in the After Action Report or action raised, it is unclear if this matter has been considered, or any actions taken to prevent future confusion.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to submit specific scan requests using the correct form and rationale
Wider context from the report “2. Evidence was received from a doctor who referred the deceased for a scan, that she had thought she had requested a CTPA to be undertaken, but the form that was used was a request for an “acute pulmonary embolus investigation” which meant that the request would be vetted and an appropriate mode of scan arranged following consideration by a radiologist. It was stated by the doctor that it would not be normal to speak to radiology regarding a request for a scan.
3. In evidence from a radiologist it was stated that a medical clinician would be expected to speak to a radiologist if there was any preference for a type of scan to be undertaken so this could be discussed. It appeared to me that the use of the correct form, need to be specific, provide rationale for a specific type of scan request , and liaising with radiology as appropriate was not appreciated in this case . As above, given that there was no radiographer involved in the After Action Report or action raised, it is unclear if this matter has been considered, or any actions taken to prevent future confusion.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether VQ or CTPA is the appropriate scan modality for suspected pulmonary embolism
Wider context from the report “1. During the course of evidence Royal College of Radiographer guidance was referred to, specifically that a CTPA scan or VQ scan where equally appropriate when considering diagnosis of a Pulmonary Embolism. A first draft of an After Action Report which was concluded without Radiographer attendance at the after action review meeting was provided at the first part heard inquest hearing on 1 August 2024. This made reference in the actions section of the report to the need to consider whether VQ scans should be replaced by CTPA's for all patients suspected of having a Pulmonary Embolism. This action was not included in an Amended After Action report provided at the resumed inquest. It is unclear whether this matter has been considered.
” Open source report
17 Dec 2021 JOAN WRIGHT · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Insufficient availability, workability and accessibility of IT facilities for timely electronic record-keeping 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
JOAN WRIGHT · 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
Joan Wright, aged 91, fell at home, sustained a fractured left femur, and underwent surgery during which a guide wire penetrated her pelvis. She later developed a severe infection in the hip and died at a nursing home on 16 June 2021. The report raised concerns that insufficient workable and accessible IT facilities caused crucial clinical information to go unrecorded, creating a risk to other patients.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability, workability and accessibility of IT facilities for timely electronic record-keeping
Wider context from the report “(1) Both the Divisional Review Report produced by the Trust and oral evidence at the inquest disclosed problems with insufficient workable IT facilities at the hospital to allow for timely record-keeping in patients' electronic notes . I was advised that all clinical staff are supposed to make records in the electronic notes and that no handwritten records are now kept. I heard evidence that staff therefore have to rely on memory, or notes written on scraps of paper, until such time as they can access the electronic records on a computer . This case provided several instances in the care of a single patient where either no notes were made at all of clinical discussions or management plans, or crucial information was omitted. I am concerned that the issues of availability, workability and accessibility of IT equipment for such recording (in the context of a reliance on paperless working) creates a risk of future deaths to other patients where crucial information may go unrecorded .
” Open source report
4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Placement without a clear understanding of the person's needs View source Failure to provide suitable ward placement due to capacity and flow constraints View source Failure to supervise eating when supervision is required View source Lack of interagency understanding of roles and responsibilities View source Failure of care coordinators to lead support and best-interests processes in acute settings View source Unclear responsibility for care decisions and placement suitability assessment View source Failure to ensure food is served at a safe temperature View source Poor-quality care documentation View source Lack of coordination and ownership of care in acute settings View source Failure to recognise lack of decision-making capacity View source See 7 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
Barry Wayne Preston · 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
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Placement without a clear understanding of the person's needs
Wider context from the report “7. His placement at Laburnum Lodge was made without a clear understanding of his needs . He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute 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 Royal Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable ward placement due to capacity and flow constraints
Wider context from the report “2. The inquest heard that he was kept on wards that were not suitable for him or his needs . The inquest was told that this was due to capacity and flow issues within the Royal Bolton 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 Royal Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise eating when supervision is required
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised , he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding of roles and responsibilities
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place. There was a lack of understanding between agencies of roles and responsibilities under the integrated care model .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of care coordinators to lead support and best-interests processes in acute settings
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place . There was a lack of understanding between agencies of roles and responsibilities under the integrated care model.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for care decisions and placement suitability assessment
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure food is served at a safe temperature
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn . The burn did not contribute to his death but did cause significant additional discomfort.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor-quality care documentation
Wider context from the report “1. The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of coordination and ownership of care in acute settings
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care . It was unclear as to who was making decisions and assessing suitability of placement.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise lack of decision-making capacity
Wider context from the report “5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care . Acquiescence by him was seen as him understanding and having capacity .
” Open source report
28 Feb 2020 Irene Whittingham · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Conflicting guidance on timing of Vitamin D and Calcium blood level monitoring View source Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses View source Failure to provide community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment 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
Irene Whittingham · 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
Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Conflicting guidance on timing of Vitamin D and Calcium blood level monitoring
Wider context from the report “1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses
Wider context from the report “3. The WellSky and EMIS Software, had a confusing user drop down menu option , which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment
Wider context from the report “1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP , regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines .
” Open source report
12 Oct 2017 Carol Buchanan · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to consult or cross-reference the Summary Care Record when prescribing View source Failure to recognise the interaction between Itraconazole and Simvastatin View source Failure to act on relevant clinical history View source Unavailability of accurate prescription documentation requiring reliance on verbal medication histories View source Delays in diagnosing the underlying cause of presenting symptoms View source Delays in implementing fluid balance monitoring View source Failure to record prescriptions in relevant records in a timely effective manner View source Failure to appreciate the importance of relevant clinical history 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
Carol Buchanan · 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
Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consult or cross-reference the Summary Care Record when prescribing
Wider context from the report “1. The prescription of Itraconazole was undertaken at the Royal Bolton Hospital’s Respiratory Clinic’s without the consultation or cross referencing information with the Summary Care Record .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the interaction between Itraconazole and Simvastatin
Wider context from the report “4. The very serious interaction between Itraconazole and Simvastatin which contributed to the cause of death was not appreciated .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to act on relevant clinical history
Wider context from the report “5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately:
a. The importance of the history not appreciated upon;
b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon ;
c. Delay in implementing delivery of fluid balance monitoring; and
d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of accurate prescription documentation requiring reliance on verbal medication histories
Wider context from the report “2. In the absence of access to such documentation , clinicians are instructed to make use of the information provided verbally by the patient/family or carer which in the event of a patient’s presentation can be incomplete or inaccurate . An extensive prescription regime can give rise to incomplete or inaccurate relevant prescription history .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosing the underlying cause of presenting symptoms
Wider context from the report “5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately:
a. The importance of the history not appreciated upon;
b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon;
c. Delay in implementing delivery of fluid balance monitoring; and
d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing fluid balance monitoring
Wider context from the report “5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately:
a. The importance of the history not appreciated upon;
b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon;
c. Delay in implementing delivery of fluid balance monitoring ; and
d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record prescriptions in relevant records in a timely effective manner
Wider context from the report “3. The prescription of Itraconazole on the 27th April 2017 was not typed up into relevant records either by way of a “GP clinic letter” or by way of a timely effective prescription .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate the importance of relevant clinical history
Wider context from the report “5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately:
a. The importance of the history not appreciated upon ;
b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon;
c. Delay in implementing delivery of fluid balance monitoring; and
d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms.
” Open source report
28 Sep 2017 Pauline Hayston · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment View source Unsuitability of wireless WiFi activation when several fall mats are in proximity View source Unreliability of Rambledguard fall mats for their intended purpose 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
Pauline Hayston · 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
Pauline Hayston, who had reduced mobility, frailty and recent falls, sustained an unwitnessed fall while attempting to mobilise as an inpatient and later died following a fractured neck of femur and resulting immobility. The concerns identified related to the reliability and fitness for purpose of the Rambledguard falls mats, the suitability of the wireless system when several mats were in use, and the absence of technical instructions for nursing staff about operational problems.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of wireless WiFi activation when several fall mats are in proximity
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Rambledguard fall mats for their intended purpose
Wider context from the report “The evidence raises the following concerns:
1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.
” Open source report
16 Feb 2016 Eric Albert Gaskell · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to provide patients with 24-hour access to required medication 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
Eric Albert Gaskell · 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
Eric Albert Gaskell attended Royal Bolton Hospital with chest pain on 6 November 2015 and was discharged with a presumed diagnosis of stable angina. He collapsed while working on 8 November 2015 and died at Salford Royal Hospital; the medical cause of death was ischaemic heart disease, coronary artery thrombus and coronary artery atheroma. The report raised concerns that Royal Bolton Hospital’s prescribing policy and pharmacy opening hours could prevent patients from obtaining medication, including potentially lifesaving medication, outside pharmacy opening times.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with 24-hour access to required medication
Wider context from the report “i. Due to the current policy adopted by the Royal Bolton Hospital regarding the prescribing of medication, a future death could occur if a person is not given 24 hour access to medication that they require and I therefore request that a review be conducted by the Royal Bolton Hospital of their policies and procedures in respect of the prescribing at the Hospital.
” Open source report
8 Oct 2015 Maureen Chatterley · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Lack of continuous stock records and verification for non-controlled ward medications View source Failure to investigate concerns about excess medication doses 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
Maureen Chatterley · 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
Maureen Chatterley died at Royal Bolton Hospital on 24 December 2014 after a fall causing a right hip fracture, subsequent dislocations and multiple surgical procedures. The report raised concerns that a possible excess dose of lorazepam was not investigated and that medication stock in patient drawers and ward cupboards was not recorded or controlled, although the Inquest accepted that any excess dose did not contribute to her death.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of continuous stock records and verification for non-controlled ward medications
Wider context from the report “1. During the Inquest evidence was heard that
i. There was no investigation by the hospital in relation to the concerns expressed by the family in relation to the administration of an excess dose of Lorazepam.
ii. There was no record of the stock of medication in relation to non-controlled drugs in the medication drawer allocated to a patient nor in and the medication cupboard on the ward. Accordingly medication could be removed from the medication cupboard on the ward and used either for an elicit purpose or excess dosage without any knowledge or record with reference to stock control.
Evidence was given at the Inquest that the pharmacist checked medications on the ward on a daily basis but there was no check or record of the number of medications or the number of tablets in the allocated medication drawers or the cupboard on ward, particularly between the daily inspections by the pharmacist.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate concerns about excess medication doses
Wider context from the report “1. During the Inquest evidence was heard that
i. There was no investigation by the hospital in relation to the concerns expressed by the family in relation to the administration of an excess dose of Lorazepam.
ii. There was no record of the stock of medication in relation to non-controlled drugs in the medication drawer allocated to a patient nor in and the medication cupboard on the ward. Accordingly medication could be removed from the medication cupboard on the ward and used either for an elicit purpose or excess dosage without any knowledge or record with reference to stock control.
Evidence was given at the Inquest that the pharmacist checked medications on the ward on a daily basis but there was no check or record of the number of medications or the number of tablets in the allocated medication drawers or the cupboard on ward, particularly between the daily inspections by the pharmacist.
” Open source report
26 Jun 2015 Brian Anthony Gillard · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Failure to hand over patients’ continuing oxygen requirements during transfers between hospital departments View source Failure of ward staff to know and identify patients’ continuing oxygen requirements View source Failure to supervise patients requiring oxygen while they are in ward facilities View source Failure to provide required oxygen during patient transfers within a ward 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
Brian Anthony Gillard · 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
Brian Anthony Gillard, who had asbestosis and required ambulatory oxygen, died at Royal Bolton Hospital on 20 March 2015 after collapsing and suffering a cardiac arrest while using the toilet. The concerns included a lack of handover about his oxygen requirement, transfer to the toilet without oxygen, and leaving him unsupervised in a toilet without an emergency pull-cord.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over patients’ continuing oxygen requirements during transfers between hospital departments
Wider context from the report “iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia.
iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of ward staff to know and identify patients’ continuing oxygen requirements
Wider context from the report “iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia.
iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise patients requiring oxygen while they are in ward facilities
Wider context from the report “iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia.
iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required oxygen during patient transfers within a ward
Wider context from the report “iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen . He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia.
iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward.
” Open source report
6 Nov 2013 William Joseph Wilkinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of direct orthopaedic input at the Emergency Department View source Failure to maintain a complete Fluid Balance Chart View source Failure of the hospital computer system to provide reliable staff access for recording clinical matters View source Unavailability of required one-to-one nursing 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.
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AI-generated summary
William Joseph Wilkinson · 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
William Joseph Wilkinson slipped on the pavement while shopping on or about 9 December 2012, fractured his ankle, was admitted to hospital, and later died after complications. Concerns included the availability of ordered one-to-one nursing, difficulties logging onto the hospital computer system, an incomplete Fluid Balance Chart, and the lack of direct orthopaedic input in the Emergency Department.
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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of direct orthopaedic input at the Emergency Department
Wider context from the report “(4) It was agreed that there was no direct orthopaedic input available at the Emergency Department at the hospital and that it would be sensible for this to have been available. Had this been available Mr Wilkinson would probably not have been admitted to the hospital in the first place with a fractured ankle and therefore would not, presumably, have developed clostridium difficile leading to his death. He was described as an unnecessary in-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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a complete Fluid Balance Chart
Wider context from the report “(3) A Fluid Balance Chart was ordered to be kept and it was accepted that this was not done and an incomplete Fluid Balance Chart resulted .
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital computer system to provide reliable staff access for recording clinical matters
Wider context from the report “(2) Members of staff reported that they sometimes find it difficult if not impossible to log onto the computer system in the hospital and therefore cannot record matters as they should be recorded . This is apparently due to the inadequacies of the system rather than the inabilities of the individuals.
” 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 Bolton Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required one-to-one nursing
Wider context from the report “(1) I was told that despite one-to-one nursing being required for Mr Wilkinson and indeed being ordered, this is not always available . There was clear evidence that had such nursing standards been available Mr Wilkinson may not have developed the problems which led to his 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