11 Feb 2026 Chloe Angela Ulett · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion View source Lack of guidance on referral pathways for raised ammonia levels View source Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated View source Failure to consider ammonia testing nationally, causing risk of delayed diagnosis View source Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion View source Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors View source Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients View source Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders View source Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine View source See 6 more concerns
Responses linked to these 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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AI-generated summary
Chloe Angela Ulett · 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
Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.
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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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients.
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on referral pathways for raised ammonia levels
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised . The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated . Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to consider ammonia testing nationally, causing risk of delayed diagnosis
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period.
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion
Wider context from the report “1. The window of opportunity to consider and make a diagnosis of a metabolic disorder and institute effective treatment is very short, 24 to 48 hours from the commencement of symptoms , and relies on early measurement of ammonia in an adult presenting with behavioural change and 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1 , and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients .
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period .
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department .
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report
19 Sep 2025 Mr Luke John Chatterton · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Lack of a national formal guideline for management of bowel obstruction View source Delays in accessing advanced life support resuscitation for detained patients View source Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location View source Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine 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
Mr Luke John Chatterton · 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 Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.
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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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of a national formal guideline for management of bowel obstruction
Wider context from the report “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics. There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing advanced life support resuscitation for detained patients
Wider context from the report “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location
Wider context from the report “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards , and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine
Wider context from the report “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction , including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics . There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.
” Open source report
Concerns raised 3 Lack of paediatric nursing observations View source Failure of medical staff to recognise absent nursing observations View source Failure to complete final nursing observations before discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Finlay Joshua ROBERTS · 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
Finlay’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to recognise absent nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to complete final nursing observations before discharge
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and pilot a revised paediatric early warning score for emergency departments.
Verbatim wording from the response “RCEM is involved in the design and piloting of a revised paediatric early warning score specifically intended for Emergency Departments.” Source location 2025-0316 Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish standards requiring emergency departments to use a specific paediatric early warning score with appropriate triggers and actions.
Verbatim wording from the response “The standards that RCEM published in 2024 in Guidelines for the provision of Emergency Services include that “Emergency Departments must use a specific paediatric early warning score and ensure that appropriate triggers and actions are in place.” All Paediatric early warning scores dictate how often observations should be checked depending on the age of the child and initial observations.” Source location 2025-0316 Response from Royal College of Emergency Medicine
Open published response
Concerns raised 4 Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source Lack of guidance for managing children with profound disabilities in hospital settings View source Failure to recognise and act on parents’ ongoing concerns about children on hospital wards View source Failure to routinely offer learning disability liaison nurse support in the emergency department View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children with profound disabilities in hospital settings
Wider context from the report “1. The management of children with profound disabilities within a hospital setting
Rose was a deeply loved child who brought great joy to her mother, wider family and all that knew her. During the inquest hearing no national or local guidance was forthcoming to assist medical and nursing staff, within a conventional hospital setting, to appropriately manage patients such as Rose who had a global developmental delay and was wholly reliant on her mother to advocate on her behalf . This gives rise to a concern that this omission adversely impacts the care that patients such as Rose receive.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on parents’ ongoing concerns about children on hospital wards
Wider context from the report “3. Nursing and Medical care on the ward
In the absence of local and national guidelines, the importance of listening and responding to Rose’s mothers ongoing concerns about her daughter when she was transferred to the ward were not recognised by the nursing and medical staff and consequently not acted upon thereby contributing to Rose’s death. There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer learning disability liaison nurse support in the emergency department
Wider context from the report “4. LeDeR Role
Rose’s admission was during the working week, yet there was no consideration or offer given to Rose or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse . This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department. This again gives rise to a concern that patients such as Rose and her mother are adversely impacted on the care that they receive in the absence of local and national guidelines that this should be routinely available and offered as a matter of course.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and maintain a Learning Disabilities Toolkit with emergency-department guidance on reasonable adjustments, intra-abdominal pathology and aspiration.
Verbatim wording from the response “1. The management of children with profound disabilities within a hospital setting
In September 2024, the Royal College of Emergency Medicine (RCEM) published a Learning Disabilities Toolkit [1]. This resource includes information about how best to approach the management of people with a learning disability and suggestions on how to make reasonable adjustments in an ED setting. The toolkit also makes specific mention of intra-abdominal pathology and aspiration. The RCEM also provide additional online educational resources related to Learning Disabilities [2]. The RCEM feel it would not be appropriate to comment about the care delivered in the in-patient setting.” Source location Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in developing the emergency-department version of the national paediatric early warning system, including parental or carer concern in escalation responses.
Verbatim wording from the response “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
The RCEM Learning Disability Toolkit [1] emphasises the importance of listening to family and carers of people with a learning disability in the ED. The RCEM are represented in the group developing the ED version of the national paediatric early warning system (nPEWS) with NHS England. A key component of the nPEWS (and the current draft of the emergency department specific nPEWS score - EDnPEWS) is parental/carer concern [3]. The response from the parent/carer is built into the escalation response. The RCEM is also supportive of the work just commencing via NHS England’s Patient Safety Collaborative, which is looking to test the use of Martha’s Rule in the ED setting. We would also note” Source location Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providing learning disability nurses within individual hospitals is outside the respondent’s remit.
Verbatim wording from the response “4. The Role of the Learning Disability Nurse
The RCEM is fully supportive of Learning Disability Nurses taking on a liaison role within the ED setting for appropriate patients. The RCEM Learning Disability toolkit specifically recommends that a member of the ED staff is identified as a link with the hospital learning disability team. The provision of Learning Disability Nurses within individual hospitals is outside of the remit of the RCEM.” Source location Response from Royal College of Emergency Medicine
Open published response
Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a safety communication to members highlighting commonly used antiemetics associated with QT prolongation or arrhythmias.
Verbatim wording from the response “Regarding the academic publication in your PFD notice [5], we note this case involved the use of three different anti-emetic agents in the same patient, including two agents which are highlighted by the BNF as causing QT prolongation prochlorperazine, ondansetron in-addition to cyclizine. However, despite our uncertainty regarding the contribution of cyclizine to Christian’s deterioration, we do feel that a safety communication with RCEM members would be worthwhile and valuable. The safety communication will highlight which commonly used anti-emetics are known to prolong the QT interval or promote arrhythmias, especially since the use of ondansetron in EDs has increased considerably since 2017. We undertake to do this before April 2026.” Source location Response from Royal College of Emergency Medicine
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include focused cardiac ultrasound for shock assessment in the emergency medicine training curriculum.
Verbatim wording from the response “Point B – Echocardiography. Regarding your concern that echocardiography was not performed prior to cardiac arrest, we can confirm that the RCEM training curriculum at the time [1] did not include cardiac ultrasound for the purposes of shock assessment, it was only included as an adjunct in the setting of cardiac arrest. It would therefore have been an unreasonable expectation that a focused cardiac ultrasound for the assessment of shock should have taken place before cardiac arrest by the emergency medicine doctor. A subsequent curriculum update in 2021 did include focused cardiac ultrasound for shock assessment for emergency medicine doctors in their last years of training [2]. The RCEM also” Source location Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Initial clinical management was appropriate because infection or sepsis was more likely than the much less likely diagnosis of cardiomyopathy.
Verbatim wording from the response “From your report, the RCEM feels that the initial clinical management in this case was appropriate given the greater likelihood of infection or sepsis being the cause of Christian’s presentation than the much less likely diagnosis of cardiomyopathy. We further feel that the clinical management plan which prioritised the delivery of time critical therapy followed by an assessment to see if the interventions had been effective was appropriate.” Source location Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pre-arrest focused cardiac ultrasound was not a reasonable expectation because the applicable emergency medicine curriculum did not include shock assessment.
Verbatim wording from the response “Point B – Echocardiography. Regarding your concern that echocardiography was not performed prior to cardiac arrest, we can confirm that the RCEM training curriculum at the time [1] did not include cardiac ultrasound for the purposes of shock assessment, it was only included as an adjunct in the setting of cardiac arrest. It would therefore have been an unreasonable expectation that a focused cardiac ultrasound for the assessment of shock should have taken place before cardiac arrest by the emergency medicine doctor. A subsequent curriculum update in 2021 did include focused cardiac ultrasound for shock assessment for emergency medicine doctors in their last years of training [2]. The RCEM also” Source location Response from Royal College of Emergency Medicine
Open published response
Concerns raised 6 Understaffing of the emergency department, including insufficient staff to take basic observations View source Failure to perform hourly observations in the emergency department View source Failure to administer the first antibiotic dose in the emergency department View source Lack of training or guidance on adult-onset asthma View source Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern View source Failure to include blood pressure in the national paediatric early warning score View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Billie Diane WICKS · 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
Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Understaffing of the emergency department, including insufficient staff to take basic observations
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations .
Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to perform hourly observations in the emergency department
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations.
Billie should have had observations every hour . If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free . Although the circumstances were different, there is a theme.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to administer the first antibiotic dose in the emergency department
Wider context from the report “2. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion . This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance on adult-onset asthma
Wider context from the report “3. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma . This seems to indicate a training and potentially a guideline need .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern
Wider context from the report “4. I heard that Billie was safely netted when she was discharged. Her parents were told to bring her back if they had any concerns.
I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction.
In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to include blood pressure in the national paediatric early warning score
Wider context from the report “5. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS) .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update existing patient-information guidance to specifically address safety-netting documentation and advice.
Verbatim wording from the response “RCEM shares your concerns regarding the use of the term ‘safety netting’ in medical notes. This term is only of value if the components of the ‘safety net’ have been documented. RCEM considers the components which relate to safety netting (as opposed to other information which might be provided to the patient) to include: [18]” Source location Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No national guidance or clear rationale supports requiring clinicians to administer the first antibiotic dose absent suspected allergy.
Verbatim wording from the response “Antibiotic administration
It is good practice for the prescribing and administration of medicines to be performed by different practitioners [8]. There is current guidance on the management of sepsis. This would suggest that for sepsis without shock, antibiotics should be administered within three hours [9]. It is unclear whether Billie had sepsis. Guidance for the time to administer the first dose of antibiotics in people with infection without sepsis are less prescriptive. RCEM notes that Billie was discharged after about three and a half hours. It is assumed that she was given antibiotics at discharge, to self-administer. Antibiotics are only part of the management for an exacerbation of asthma thought to be secondary to a bacterial” Source location Response from Royal College of Emergency Medicine
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The response cannot comment on the hospital emergency department’s staffing model, staffing numbers or skill mix.
Verbatim wording from the response “Staffing
We are unable to comment about the staffing model, numbers, or skill mix, at The Royal Free Hospital’s emergency department. The Royal College of Emergency Medicine (RCEM) has guidance regarding the level of staffing for doctors [1], nurses, and healthcare staff [2]. In December 2024, the RCEM also published standards around staffing [3], [7]. Each ED should have a senior decision-making (tier 4) doctor in the department at all times [3, 7]. A tier 4 doctor may be referred to as a registrar. Adequate staffing is required to deliver safe care.” Source location Response from Royal College of Emergency Medicine
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National PEWS is not currently supported for use in emergency departments; an ED-specific version is being developed and tested.
Verbatim wording from the response “Physiological Observations
Each emergency department (ED) should have a track and trigger tool for children (of all ages) [3] and adults. There are several different scores that are referred to as PEWS. The national paediatric early warning system (nPEWS) was designed for inpatient use, and a new ED version is currently being developed and tested. NEWS2 and nPEWS both include blood pressure monitoring. RCEM and the Royal College of Paediatrics and Child Health, do not currently support the use of nPEWS in the ED [5,6]. It is acceptable to use the adult national early warning score (NEWS2) in children aged 16 and above [4]. Both nPEWS and NEWS2 have suggested frequency of repeat observations depending on the initial set of observations performed.” Source location Response from Royal College of Emergency Medicine
Open published response
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Pamela Anne Marking · 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
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a position statement setting standards for Physician Associate supervision, identification, patient selection and regulation.
Verbatim wording from the response “Following a period of consultation and engagement with various stakeholders, in June 2024 the Royal College of Emergency Medicine (RCEM) issued a position statement regarding Physician Associates [1] which included the following:” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update workforce-tier guidance to classify Physician Associates at Tier 1 and recommend discussion or review of their patients by Tier 4 or 5 doctors.
Verbatim wording from the response “RCEM has recently, after an extensive consultation period, updated our workforce tiers guidance. This guidance was originally published in February 2015 and outlines what level of supervision clinicians with different levels of experience and training should be working at. The current guidance makes explicit reference to PAs as working at Tier 1 level and makes a specific recommendation that patients seen by a PA should be discussed with or reviewed” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contribute to the ongoing review of the safety and scope of the Physician Associate role.
Verbatim wording from the response “The role and regulation of PAs has been subject to much comment in recent years [3], we note that there is an ongoing review into the safety and scope of the PA role [4] to which RCEM is contributing. RCEM is responsible for setting standards of training, administering examinations and awarding Fellowship and Membership of the College as well as supporting Post Graduate Doctors in Training to qualify in the specialty of Emergency Medicine. The College works to ensure high quality patient care by setting and monitoring standards. We provide expert guidance and advice on health policy to relevant bodies on matters relating to Emergency Medicine and advocate and influence policy makers and politicians on behalf of our members and the wider specialty. It should be noted that RCEM does not have any statutory or regulatory role.” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College will not comment on the provision of general anaesthesia in operating theatres.
Verbatim wording from the response “RCEM does not feel it would be appropriate to comment on matters related to the provision of general anaesthesia in the operating theatre.” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitoring or accrediting physician associate training is outside the College’s responsibility.
Verbatim wording from the response “RCEM is not responsible for monitoring or accrediting PA training.” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College has no statutory or regulatory role in regulating physician associates.
Verbatim wording from the response “The role and regulation of PAs has been subject to much comment in recent years [3], we note that there is an ongoing review into the safety and scope of the PA role [4] to which RCEM is contributing. RCEM is responsible for setting standards of training, administering examinations and awarding Fellowship and Membership of the College as well as supporting Post Graduate Doctors in Training to qualify in the specialty of Emergency Medicine. The College works to ensure high quality patient care by setting and monitoring standards. We provide expert guidance and advice on health policy to relevant bodies on matters relating to Emergency Medicine and advocate and influence policy makers and politicians on behalf of our members and the wider specialty. It should be noted that RCEM does not have any statutory or regulatory role.” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The supervising doctor decides whether a patient seen by a physician associate requires face-to-face review or discussion.
Verbatim wording from the response “by a tier 4 or 5 doctor [2]. The decision as to whether a patient has a face-to-face review rather than a discussion, is for the judgement of the supervising doctor who will need to take into account many factors, including those which are patient related (e.g. potential seriousness of the presentation, co-existent illnesses) as well as those which are clinician related.” Source location Response from RCEM
Open published response
29 Aug 2024 Kasey Beech · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration View source Failure to assess potentially life-threatening non-cardiac causes alongside cardiac causes of pain View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kasey Beech · 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
Kasey Beech attended Medway Maritime Hospital with difficulty breathing and chest pain, was directed to a service with a reported three-hour wait, and later suffered a cardiac arrest after her breathing suddenly worsened. She died at St Thomas’ Hospital on 13 October 2021 following treatment. The report raises concerns that the STREAMing model’s focus on current cardiac-sounding chest pain may delay consideration of other immediately life-threatening causes of deterioration, including infective exacerbation of asthma.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to assess potentially life-threatening non-cardiac causes alongside cardiac causes of pain
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to promote standardised initial assessment for emergency-department patients.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance on emergency-department initial assessment and triage.
Verbatim wording from the response “The Royal College of Emergency Medicine (RCEM) has issued the following guidance regarding the initial assessment (triage) of patients [1]” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with NHS England to standardise initial-assessment definitions and processes.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the effectiveness of current triage systems using evidence.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Help design a new initial-assessment process for implementation across emergency departments in England.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Insufficient information about the UTC’s role and STREAMing Model prevents a specific response to concerns about prioritising chest pain.
Verbatim wording from the response “We note the initial assessment took place in an Urgent Treatment Centre (UTC) rather than Emergency Department (ED); from the described circumstances of Ms Beech’s death, it is not clear whether the UTC was effectively ‘gatekeeping’ access to an emergency department or not. Regarding the Simple Triage Rapid Emergency Assessment Method ‘STREAMing Model’ª, we have not been able to find any specific details regarding what appears to be an initial assessment tool, and we do not believe that this is an assessment tool that is routinely used in emergency departments. As a consequence, we are not able to provide any specific response to your concerns regarding the apparent prioritisation of cardiac sounding chest pain over other potentially life-threatening conditions.” Source location Response from RCEM
Open published response
Concerns raised 2 Failure to explicitly emphasise prompt escalation when observations cannot be obtained View source Emergency department electronic patient records failing to show repeat presentations during the current illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel KLOSI · 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
Daniel died on his fourth presentation in a week to the Royal Free Hospital, with group A streptococcus sepsis recorded as the medical cause of death. Concerns included the delay in obtaining a full set of observations when he was distressed, and electronic records not showing how many times a patient had attended hospital with the same signs and symptoms during the current illness.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to explicitly emphasise prompt escalation when observations cannot be obtained
Wider context from the report “1. It was difficult for the nursing staff to obtain Daniel’s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance Daniel did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.
I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations, and should be escalated without delay .
It seems that this has not been emphasised explicitly to nursing and medical staff at the trust – and obviously may not have been in other trusts.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Emergency department electronic patient records failing to show repeat presentations during the current illness
Wider context from the report “2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support early escalation of care when vital signs cannot be obtained.
Verbatim wording from the response “The RCEM is an active participant in the national initiative to develop an early warning score (that utilises observations or vital signs) that is specifically designed for use on all children attending emergency departments, following the implementation of a paediatric early warning score for children who are in hospital wards [11]. We will continue to develop supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing a paediatric early warning score for children attending emergency departments.
Verbatim wording from the response “The RCEM is an active participant in the national initiative to develop an early warning score (that utilises observations or vital signs) that is specifically designed for use on all children attending emergency departments, following the implementation of a paediatric early warning score for children who are in hospital wards [11]. We will continue to develop supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.” Source location Response from RCEM
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England should address emergency department electronic record configuration showing previous presentations with the same signs and symptoms.
Verbatim wording from the response “With regards your specific concerns about emergency department electronic patient records (EPR) and their configuration to show how many times a patient has presented to hospital with the same signs and symptoms as their current presentation, we feel this question is best directed towards NHS England.” Source location Response from RCEM
Open published response
1 Aug 2024 Derryck Lynn CROCKER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to recognise and report air embolism cases View source Delays in recognising air embolism View source Delays in treating air embolism View source Lack of nationally consistent air embolism awareness training across relevant specialties View source Lack of knowledge and training on recognising air embolism following invasive procedures View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derryck Lynn CROCKER · 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
Derryck Crocker underwent a CT-guided lung biopsy on 3 May 2023 and subsequently developed a cerebral air embolism, deteriorated, and died on 10 May 2023. The principal concerns were limited recognition of air embolism following invasive procedures, insufficient training and awareness across medical specialties, and delays in recognition and treatment that may increase the likelihood of 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and report air embolism cases
Wider context from the report “2. I also heard evidence that in areas where enhanced training has been provided, due to adverse incidents such as Mr Crocker’s death, there appears to be increased numbers of cases. This leads to the question of whether the lack of knowledge means that such cases are missed and unreported and the rise is due to greater awareness.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising air embolism
Wider context from the report “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in treating air embolism
Wider context from the report “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally consistent air embolism awareness training across relevant specialties
Wider context from the report “4. I heard evidence that there is ongoing work with the Royal College of Radiologists to provide them training on this issue, but that training was needed to ensure that all other specialties who may encounter this condition have raised awareness nationally .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and training on recognising air embolism following invasive procedures
Wider context from the report “1. I heard evidence that there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure . I heard evidence that nationwide and across all levels of specialism and seniority, there was a lack of knowledge and that air embolism is not something that is routinely taught as part of the training of doctors . While it is accepted that this is rare, it is life threatening if not appropriately treated swiftly.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider providing specific air-embolism recognition and management guidance through the RCEM eLearning platform.
Verbatim wording from the response “We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform.” Source location Response from Royal College of Emergency Medicine
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-issue a previously published air-embolism case report to raise awareness among members.
Verbatim wording from the response “We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform.” Source location Response from Royal College of Emergency Medicine
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The air embolism occurred outside the emergency department and was a rare known complication of lung biopsy.
Verbatim wording from the response “We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform.” Source location Response from Royal College of Emergency Medicine
Open published response
13 Jun 2024 Joseph Lawrence Parker · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to endorse and disseminate PUMA airway management guidance View source Lack of changes following previous Prevention of Future Deaths Reports concerning unrecognised oesophageal intubation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Lawrence Parker · 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
Joseph Lawrence Parker took an overdose of medication on 17 February 2022, collapsed, and was taken to Southmead Hospital for intubation. The breathing tube was accidentally positioned in the oesophagus and the misplacement was not identified promptly, contributing to cardiac arrest, hypoxic encephalopathy, and his death on 16 April 2022. The principal concerns relate to recognising incorrect tube placement, the use and interpretation of capnography, and the dissemination of relevant airway-management guidance.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to endorse and disseminate PUMA airway management guidance
Wider context from the report “(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.
(2) That the more recent PUMA (Project for Universal Management of Airways) guidelines state, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet.
(3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer.
(4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of changes following previous Prevention of Future Deaths Reports concerning unrecognised oesophageal intubation
Wider context from the report “(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.
(2) That the more recent PUMA (Project for Universal Management of Airways) guidelines state, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet.
(3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer.
(4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve existing guidance to emphasise waveform capnography for early recognition of oesophageal intubation.
Verbatim wording from the response “These and other standards and recommendations currently form part of an existing document which provides a framework for collaborative working between Emergency Medicine (EM) and Intensive Care Medicine (ICM) [1]. As a specialty we will continue to work closely with the Faculty of Intensive Care Medicine and seek to improve upon our existing guidance to highlight the importance of waveform capnography in the early recognition of oesophageal intubation.” Source location Response from Royal College of Emergency Medicine
Open published response
7 Nov 2023 Michael John VINCENT · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Long lie after a fall in elderly people View source Failure to provide allocated ambulance responses within the expected response time 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
Michael John VINCENT · 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 John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Long lie after a fall in elderly people
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death . Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to provide allocated ambulance responses within the expected response time
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay , during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin . There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience . Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” Open source report
Concerns raised 2 Delays in Radiologist review of emergency chest x-rays View source Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chantelle Reed · 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
Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in Radiologist review of emergency chest x-rays
Wider context from the report “2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists . The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died . In an emergency situation such as this one, this delay represents on ongoing risk of future deaths .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw
Wider context from the report “1. The evidence of the independent expert in Emergency Medicine, was that “the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection . Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain . The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for those responsible for compiling guidelines to consider including this symptom to raise the profile of possible aortic dissection further ”. The expert felt that this would assist in cases such as Chantelle’s where the presentation did not have many of the usual ‘red flag’ symptoms.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Radiating chest pain does not by itself warrant mandatory TAD investigation or CTA for all such patients because benefits do not outweigh risks.
Verbatim wording from the response “You have asked us to address two specific areas of concern, the first of which was the nature of the chest pain which was described as radiating to the neck and jaw and whether this should have raised the possibility of Thoracic Aortic Dissection (TAD). Unfortunately chest pain which radiates to the neck or jaw is not specific for TAD and this description is much more likely to be in keeping with other pathology such as acute coronary syndrome (heart attacks and angina); in fact acute coronary syndrome is 100-200 times more common than TAD [1]. The most discriminating description of the chest pain that is experience in TAD that is evidence based is described as sudden onset with its worst severity being at its onset [2,3]. As noted in your report, TAD in a woman of Ms Reed’s age is highly unusual and we would consider this a rare occurrence in the absence of any other risk factors.” Source location Response from The Royal College of Radiologists
Open published response
15 Aug 2023 Leonard Jomo Isaac KING · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to recognise epiglottitis in adults 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
Leonard Jomo Isaac KING · 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
Leonard Jomo Isaac King died at Milton Keynes University Hospital on 4 May 2022 following a hypoxic cardiac arrest caused by airway obstruction from epiglottitis. The report identified concerns that adult epiglottitis may be mistaken for a sore throat or tonsillitis, and that there were missed opportunities to recognise and escalate his condition and transfer him to an 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise epiglottitis in adults
Wider context from the report “Subsequent to mass immunisation the demographic has changed and more adults are developing epiglottitis. It is not common in this group but because of the expectation among clinicians that it is a still a disease of children, there is a tendency, except in those routinely dealing with acute emergencies of the airways, to regard typical symptoms as those of a sore throat or tonsillitis and not as the harbinger of sudden catastrophic obstructive epiglottitis .
The disease classically develops rapidly in children but in adults may take several days which may be falsely reassuring . Typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice. Prompt recognition and treatment is lifesaving.
” Open source report
28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to document general practice assessment of febrile seizures View source Failure to make timely referrals from general practice to secondary medical services for febrile seizures View source Sudden unexpected death in childhood following febrile seizures View source Failure to make paramedic information available to all clinicians View source Lack of coordinated response across clinicians to febrile seizure presentations View source Delays in referral for assessment and investigation of febrile seizures View source Failure to ensure febrile seizure diagnoses are supported by the child’s presentation View source Failure to undertake a detailed history and full neurological examination in general practice View source Failure to follow escalation guidance for complex febrile seizures View source Insufficient information for parents and guardians after a child’s febrile seizure View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Louis James Rogers · 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to document general practice assessment of febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely referrals from general practice to secondary medical services for febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Sudden unexpected death in childhood following febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’ . Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to make paramedic information available to all clinicians
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated response across clinicians to febrile seizure presentations
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in referral for assessment and investigation of febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure febrile seizure diagnoses are supported by the child’s presentation
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a detailed history and full neurological examination in general practice
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to follow escalation guidance for complex febrile seizures
Wider context from the report “3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children
JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient information for parents and guardians after a child’s febrile seizure
Wider context from the report “2. Information provided to parents/guardians after their child had a Febrile Seizure
Evidence was heard that the NHS website and pamphlet provided to parents/guardians following a child’s febrile seizure is insufficiently informative to provide parents with sufficiently detailed information to assist them in picking up potential early indicators of a more severe illness e.g. issues with gait, co-ordination, definition of complex seizures, developmental regression etc.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Verbatim wording from the response “RCEM would be happy to work with NHS England / National Institute for Healthcare Excellence, Royal Colleges and other interested parties to help develop further evidence based or consensus guidance in this complex area of clinical practice. We are mindful that this would be a significant undertaking and that it would therefore not be appropriate for RCEM to take the lead on such a project.” Source location Response from Emergency Care Committee
Open published response
8 Jun 2022 Mr Ian McDonald Taylor · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to provide access to prescribed emergency inhaler medication during public-place police detention View source Failure to identify and address officer training or attitudinal deficits through supervision View source Failure to conduct and record an adequate ongoing risk assessment View source Failure to communicate detainee medical distress with appropriate urgency View source Unavailability of timely paramedic response during exceptional ambulance-service demand View source See 2 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
Mr Ian McDonald Taylor · 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 Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to prescribed emergency inhaler medication during public-place police detention
Wider context from the report “Mr Taylor was in police detention in a public place and was known to be a sufferer of both COPD and asthma, required to take a regular combination of inhalers and had a history of emergency admission to hospital with life threatening asthma. He repeatedly asked urgently for his inhaler, which he said was in his pocket, and that he needed it and that he felt he was going to die. Police did not find it (although a broken inhaler found later at the scene might have been his). If he had been in a custody suite he would have had access to a custody nurse or medical practitioner who could have prescribed it.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address officer training or attitudinal deficits through supervision
Wider context from the report “In court he was asked if he had learnt any lessons from the incident and he did not acknowledge he had. He was asked if he would do anything different in future, he made excuses for his comments and he said that he would be more sensitive in future. He was not able to answer a question about what considerations should be made to form the view somebody did not need hospital. He did not accept that he had made an inadequate risk assessment. He did not accept that such comments could have or might in future contribute to death by indicating a lack of urgency to a sergeant not at the scene. He was given an opportunity to make any other comment and could not bring himself to apologize to the family.
There was no evidence heard in court of the content or effect of supervision of the officer after the incident or whether training or attitudinal deficits had been identified and addressed. The family are concerned as to whether the officer should be suspended pending further investigations, and I disclose that merely as a measure of their level of concern about public safety, as it is inappropriate for me to make any such recommendation.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and record an adequate ongoing risk assessment
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate detainee medical distress with appropriate urgency
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely paramedic response during exceptional ambulance-service demand
Wider context from the report “Because of wholly exceptional demands on the ambulance service, a paramedic was not available until after he had suffered a cardio-respiratory arrest , from which he did not survive. A consultant paramedic and London Ambulance Service Director was asked about the feasibility of an inhaler device being available to police to offer to known asthmatics in exceptional circumstances when medical help was not available, such as is now in place in schools. He said that there were many difficulties: The difficulties included the adequacy of assessment of need by non medically trained persons on the scene, the difficulties of remote assessment, the threshold for confirmation of the person in distress being an established asthmatic, avoiding giving it to those with non asthmatic causes of breathlessness, and police training. Nevertheless he said that lives might be saved and it should be looked at. Advice was given to the court that such a proposal would need legislative change.
” Open source report
28 Apr 2021 Mr Paul Sartori · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to document the decision-making process and rationale for redirecting patients from A&E View source Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection View source Failure to record a full set of observations, including a pain score, before diverting patients from A&E View source Insufficient access to CT scanning for suspected aortic dissection View source Failure to recognise and diagnose acute thoracic aortic dissection View source Failure to update streaming guidance in line with relevant learning and guidance View source Failure to embed THINK AORTA learning into emergency department practice at all levels View source Failures in transfer of patients with suspected aortic dissection to specialist centres View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Paul Sartori · 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
Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to document the decision-making process and rationale for redirecting patients from A&E
Wider context from the report “2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department. The nurse did not document her decision making process and rationale for redirecting Mr Sartori from A&E .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to record a full set of observations, including a pain score, before diverting patients from A&E
Wider context from the report “2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department . The nurse did not document her decision making process and rationale for redirecting Mr Sartori from A&E.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient access to CT scanning for suspected aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and diagnose acute thoracic aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection . The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem .
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to update streaming guidance in line with relevant learning and guidance
Wider context from the report “1. The Inquest heard evidence that the streaming guidance in place for Barts Health A & E staff and NELFT staff had not been updated to take into account the learning from the death of Mr Sartori and to take into account the guidance from the THINK AORTA Campaign (launched in 2016).
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to embed THINK AORTA learning into emergency department practice at all levels
Wider context from the report “3. A junior sister who provided evidence at the Inquest was not aware of the THINK AORTA campaign . The Inquest heard that the senior leadership team had recently agreed to embed the THINK AORTA learning into practice at all levels within the emergency department. This learning had not been embedded at the time of the Inquest hearing .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failures in transfer of patients with suspected aortic dissection to specialist centres
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop specific aortic dissection learning modules for members and fellows.
Verbatim wording from the response “The Royal College of Emergency Medicine has been working on raising the awareness amongst the Emergency Department clinicians regarding aortic dissection. The Royal College of Emergency Medicine has worked to increase awareness to its members and fellows through the use of communications and safety notices as well as developing specific learning modules for members and fellows. The College is also developing guidance for the assessment of patients, and identification of those that require CT scanning (see below).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise guidance for assessing patients and identifying those requiring CT scanning for suspected aortic dissection.
Verbatim wording from the response “The Royal College of Emergency Medicine has been working on raising the awareness amongst the Emergency Department clinicians regarding aortic dissection. The Royal College of Emergency Medicine has worked to increase awareness to its members and fellows through the use of communications and safety notices as well as developing specific learning modules for members and fellows. The College is also developing guidance for the assessment of patients, and identification of those that require CT scanning (see below).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise clinician awareness of aortic dissection through communications and safety notices.
Verbatim wording from the response “The Royal College of Emergency Medicine has been working on raising the awareness amongst the Emergency Department clinicians regarding aortic dissection. The Royal College of Emergency Medicine has worked to increase awareness to its members and fellows through the use of communications and safety notices as well as developing specific learning modules for members and fellows. The College is also developing guidance for the assessment of patients, and identification of those that require CT scanning (see below).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the CT-scanning guideline to members and publish it on the College website.
Verbatim wording from the response “A Healthcare Safety Investigation Branch (HSIB) investigation recently recommended that the Royal College of Emergency Medicine and the Royal College of Radiologists work together to increase the awareness of aortic dissection, the accessibility of CT scanning to diagnose aortic dissection, and to develop guidance on the identification of aortic dissection. The Royal College of Emergency Medicine is in the process of finalising a Guideline, based on the limited evidence that is available on the selection of patients for CT scanning. This will be circulated to our 10,000+ members and published on our website for public viewing. It is planned that this will be endorsed by the Royal College of Radiologists, to raise awareness amongst Radiologists. It should be remembered that CT scanning is not without its own associated harms (significant radiation exposure and kidney damage).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE and NHS Pathways should help raise awareness of aortic dissection across the whole healthcare system.
Verbatim wording from the response “It is also noted that the patient presented with chest pain and the National Guidance from the National Institute of Clinical Excellence on Chest Pain of Acute Onset (NICE CG95) does not provide clear guidance regarding screening for or consideration of aortic dissection in this group of patients. The Royal College of Emergency Medicine would therefore respectfully suggest that a number of organisations with high-level reach and importance such as NICE and NHS pathways should also be engaged with the process of raising awareness within the whole system.” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
Open published response
3 Apr 2020 Andrew Spencer Wing · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to provide radiographers with the differential diagnosis when requesting remote X-ray review View source Insufficiently detailed clinical information for radiographer X-ray reviews View source Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis 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
Andrew Spencer Wing · 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
Andrew Spencer Wing had a history of untreated hypertension and was discharged from hospital after investigations for acute left-sided pain, without a CT aorta being undertaken. He subsequently died from the effects of an aortic dissection. The principal concerns were that the chest X-ray and recognised possibility of aortic dissection should have led to a CT aorta, and that radiographers reviewing X-rays were given sparse clinical 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 Royal College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to provide radiographers with the differential diagnosis when requesting remote X-ray review
Wider context from the report “1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection . If he had been made aware of this he would have advised that a CT Aorta be undertaken .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed clinical information for radiographer X-ray reviews
Wider context from the report “2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis
Wider context from the report “1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken . Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken.
” Open source report
Concerns raised 2 Lack of guidance on monitoring patients after administration of an anaesthetic nerve block View source Lack of recognition among emergency medicine professionals of relative opioid toxicity after local anaesthetic nerve block 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
Pamela Margaret Hands aka Horner · 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
Pamela Margaret Hands, also known as Horner, fell at home and was admitted to hospital with a periprosthetic femur fracture. After receiving opioid analgesia and a local anaesthetic nerve block, she was not adequately observed, was found unresponsive, and died on 1 December 2015. The principal concerns were inadequate monitoring after the block, insufficient recognition of relative opioid toxicity, and the absence of national guidance on post-procedure monitoring and related risks.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on monitoring patients after administration of an anaesthetic nerve block
Wider context from the report “The Expert Consultant in Pain Medicine explained that after the fascia iliac block was administered analgesia will occur over 10-15 minutes. As the patient obtains better analgesia from the fascia iliac block, the opioids in the circulation would have a more toxic effect than an analgesic effect. Pain is a potential arousal stimulus keeping the patient awake and aware of their surroundings. Pain is also a respiratory stimulant. There is an intimate link between the neurophysiology of pain and the respiratory stimulant. It was recognised that removing a painful stimulus using a local anaesthetic block can pre-dispose patients who have had opioids to respiratory depression. The risk can be increased if the patient has other respiratory depressant risks such as alcohol which can act synergistically with the opioid. In order to avoid this, the patient would need to be observed during the first 30 minutes after the administration of the block to reverse the effect of the opioid or support the respiration if required to avoid a cardiac arrest and death.
At the time of the death were no National Guidelines to advise on the need to monitor patients post procedure or application of the anaesthetic nerve block
At inquest it was clear from the evidence of the Clinical Director of Emergency Medicine that in 2015 the effect of relative opioid toxicity following the administration of a local anaesthetic nerve block for proximal femur fractures was not widely recognised within Emergency Medicine. As there was an increase in the use of fascia iliac block in conjunction with opioid analgesia in emergency medicine, this risk should be highlighted to health professionals so that they were aware of the risk and the appropriate guidelines put in place.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition among emergency medicine professionals of relative opioid toxicity after local anaesthetic nerve block
Wider context from the report “The Expert Consultant in Pain Medicine explained that after the fascia iliac block was administered analgesia will occur over 10-15 minutes. As the patient obtains better analgesia from the fascia iliac block, the opioids in the circulation would have a more toxic effect than an analgesic effect. Pain is a potential arousal stimulus keeping the patient awake and aware of their surroundings. Pain is also a respiratory stimulant. There is an intimate link between the neurophysiology of pain and the respiratory stimulant. It was recognised that removing a painful stimulus using a local anaesthetic block can pre-dispose patients who have had opioids to respiratory depression. The risk can be increased if the patient has other respiratory depressant risks such as alcohol which can act synergistically with the opioid. In order to avoid this, the patient would need to be observed during the first 30 minutes after the administration of the block to reverse the effect of the opioid or support the respiration if required to avoid a cardiac arrest and death.
At the time of the death were no National Guidelines to advise on the need to monitor patients post procedure or application of the anaesthetic nerve block
At inquest it was clear from the evidence of the Clinical Director of Emergency Medicine that in 2015 the effect of relative opioid toxicity following the administration of a local anaesthetic nerve block for proximal femur fractures was not widely recognised within Emergency Medicine . As there was an increase in the use of fascia iliac block in conjunction with opioid analgesia in emergency medicine, this risk should be highlighted to health professionals so that they were aware of the risk and the appropriate guidelines put in place.
” Open source report
27 Sep 2017 Master Peter Kollar · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to recognise the seriousness of jaundice in children View source Failure to escalate children with jaundice to suitable specialist care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Master Peter Kollar · 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
Master Peter Kollar, a young child, presented to hospital with diarrhoea and jaundice but was diagnosed with carotenemia and discharged without blood tests, investigation, admission or consultant escalation. An expert raised concern that jaundice in children after the neonatal period was under-recognised and that failure to escalate a child with jaundice to an appropriate specialist could adversely affect care and be potentially life threatening. Peter died aged 3½ from multi-organ failure with pulmonary haemorrhage following acute liver failure and an unidentified inborn error of metabolism, with viral infections also recorded; the conclusion was natural causes.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the seriousness of jaundice in children
Wider context from the report “████████ Professor of Paediatric Hepatology, Birmingham gave an expert opinion. She said that jaundice is rare in children after the neonatal period and that its seriousness was under recognised by both paediatricians and emergency doctors . She considered that, whilst it made no difference to the outcome in this case, the non escalation of a young child with jaundice to a suitable specialist adversely affects their care and is potentially life threatening. There will be instances when a child presents with a primary liver cause of hepatic failure where prompt referral for support and the possibility of organ transplantation was critical.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate children with jaundice to suitable specialist care
Wider context from the report “████████ Professor of Paediatric Hepatology, Birmingham gave an expert opinion. She said that jaundice is rare in children after the neonatal period and that its seriousness was under recognised by both paediatricians and emergency doctors. She considered that, whilst it made no difference to the outcome in this case, the non escalation of a young child with jaundice to a suitable specialist adversely affects their care and is potentially life threatening . There will be instances when a child presents with a primary liver cause of hepatic failure where prompt referral for support and the possibility of organ transplantation was critical .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adding jaundice to the Paediatric Early Warning Score is not considered justifiable or effective.
Verbatim wording from the response “Early Warning Scores are usually developed by rigorous primary research studies. The presence of jaundice after the immediate neonatal period is rare. Many other features that would indicate a seriously ill child are not part of the PEWS, such as abnormal cry or bulging fontanelle. Early Warning Scores are never designed to replace clinical judgement, but merely indicate to a clinician that the patient may be ill. The group unanimously concluded that it would not be justifiable or effective to amend the Paediatric Warning Score to include jaundice.” Source location 2017-0234-Response-by-The-Royal-College-of-Emergency-Medicine
Open published response
Concerns raised 1 Unnecessary use of Cyclizine in severe heart failure despite cardiac 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.
×
AI-generated summary
Beryl WALTERS · 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
Beryl Walters presented to A&E with atypical chest pain and a posterior myocardial infarction. After receiving Cyclizine for nausea, she became hypotensive and tachycardic and suffered a cardiac arrest from which she could not be resuscitated; the substantive concern was the use of Cyclizine in acute coronary events despite an available alternative antiemetic and evidence advising against its use in these circumstances.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Unnecessary use of Cyclizine in severe heart failure despite cardiac risk
Wider context from the report “(1) The British National Formulary states in the cautions part of the section on Cyclizine “severe heart failure; may counteract haemodynamic benefits of opioids,... ”
(2) The paper attached, whilst itself drawing the reader’s attention to the possible non-transferability of the findings to the emergency department, and the limited group of patients the original 1988 study was based on, makes a recommendation not to use Cyclizine in these circumstances .
(3) The availability of an alternative antiemetic, Metoclopramide, which does not appear to share the same cardiac risk profile, would seem to suggest that the use of Cyclizine is an unnecessary risk in these circumstances .
” Open source report
12 Sep 2014 Evelyn Mary Smith · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5 Failure to accurately and consistently record vital signs View source Lack of clinician knowledge of the croup severity scoring system View source Lack of paediatric expertise in the sole clinical contact for children attending A&E View source Difficulty entering Paediatric Early Warning Scoring information into GP medical records View source Failure of the GP computer system to alert clinicians to complete clinically relevant parameters View source See 2 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
Evelyn Mary Smith · 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
Evelyn Mary Smith was 7 years old when she died after an acute deterioration in her breathing at home on 13 September 2013, following several healthcare consultations for croup-like symptoms. A post-mortem examination identified Parainfluenza Virus Type 2 and Staphylococcus Aureus, resulting in Acute Ulcerative Laryngotracheobronchitis. The principal concern was that a relatively inexperienced paediatric doctor was the only clinical contact for a child attending A&E, and that discussion with the paediatric team might have led to longer observation and consideration of non-viral causes.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately and consistently record vital signs
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness . I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician knowledge of the croup severity scoring system
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care . However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric expertise in the sole clinical contact for children attending A&E
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician, who raised concerns regarding the paediatric experience of the FY2 doctor in A&E . His concern was that, whilst the care provided was not manifestly inappropriate or incorrect, he considered that discussion with the paediatric team may have prompted a longer period of observation and consideration of non-viral causes of croup-like signs. I share his overarching concern that a doctor, relatively inexperienced in paediatrics, should be the only clinical contact for a child taken to A&E .
I heard from the Hospital Trust that mandating all FY2 doctors to have postgraduate experience in paediatrics, before they were allocated to work in A&E, might have significant resource implications and may not be feasible.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Difficulty entering Paediatric Early Warning Scoring information into GP medical records
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records .
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of the GP computer system to alert clinicians to complete clinically relevant parameters
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it . I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” Open source report
Concerns raised 7 Failure to examine patients prior to chest drain insertion View source Incorrect interpretation of the cardiac silhouette View source Misinterpretation of chest x-rays View source Failure to use a lead anatomical marker when taking chest x-rays View source Failure by clinicians to identify incorrectly labelled chest x-rays View source Failure to consider both chest x-rays View source Incorrect labelling of chest x-rays View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gerald Trevor WERRETT · 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
Gerald Trevor Werrett was admitted to hospital with an infective exacerbation of chronic obstructive airways disease and other co-morbidities. During treatment, a chest drain was mistakenly inserted on the left instead of the right after chest X-rays were inverted, mislabelled and misinterpreted. The inquest concluded that he died from bilateral bronchopneumonia, chronic obstructive airways disease and ischaemic heart disease, with his death contributed to by the misplaced chest drain; concerns included failures in X-ray marking, labelling, interpretation, review and examination before insertion.
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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to examine patients prior to chest drain insertion
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain .
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Incorrect interpretation of the cardiac silhouette
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Misinterpretation of chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to use a lead anatomical marker when taking chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure by clinicians to identify incorrectly labelled chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to consider both chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered .
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 College of Emergency Medicine; that does not assign responsibility.
PFD Monitor interpretation Incorrect labelling of chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled , and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local services should review the environment, clinician training, ultrasound availability and rapid reporting arrangements.
Verbatim wording from the response “Following this incident, the key things we feel that should be reviewed locally are whether the environment supports the review of X-rays (e.g. availability of IT in the room where the procedure was carried out), if the doctor was trained in the use of ultrasound guidance for insertion of chest drains and whether ultrasound was available, in addition to the availability of rapid 24 hour reporting.” Source location 2014-0355-Response-by-The-College-of-Emergency-Medicine
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations