8 Apr 2026 Gary STARBUCK · Prevention of Future Deaths report Surrey
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Concerns raised 1 Lack of mandated care standards for privately treated patients View source
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Gary STARBUCK · 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
Gary STARBUCK developed metastatic cutaneous squamous cell carcinoma after recurrent skin cancer affecting his right pinna and died at home on 16 August 2021 following palliative care. The concern was that mandated care standards, including referral to specialist skin multidisciplinary teams, applied to NHS patients but not necessarily to privately treated patients, creating a risk that privately treated patients could receive inferior care and a risk of death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated care standards for privately treated patients
Wider context from the report “The Inquest heard evidence that Mr. Starbuck’s care and treatment for his skin cancers was initially provided privately. National guidance published by the National Institute for Health and Care Excellence (NICE) sets out that any patient with a high risk Squamous Cell Carcinoma (SCC) should be referred to a specialist skin MDT (SSMDT.). Specifically, this is something which should have occurred following excision of a SCC. This is mandated practice within the NHS and the overwhelming evidence before me was that this applied to clinicians practicing in NHS.
The situation in relation to patients being treated privately was less clear; evidence from several witnesses ranged from the position that this guidance was as binding on clinicians treating patients privately as in NHS, to the guidance was just that ‘guidance’ to be applied by the clinician within the framework of care being provided privately. The latter was relevant in the context of how clinicians treating patients privately would access the SSMDT. The evidence received was that normally this was via the treating clinician taking the patient to the relevant NHS SSMDT or in less frequent occasions where the Hospital had a private SSMDT to deal with patients being treated privately.
No mandatory policy exists beyond the NICE guidance. As a consequence, whilst the policy is mandated for patients in receipt of NHS Care and Treatment, it is not mandatory for patients being treated for the same conditions privately.
There are many clinicians who import the NICE Guidelines into their private practice, along with NHS Trusts who accept referrals from clinicians treating patients privately into the SSMDT for consideration. However, as this is not mandated practice for either clinicians or convenors of SSMDT’s , the consequence is that patients treated privately are at risk of receiving inferior care to those treated under the NHS , often within the same physical hospital setting.
I am concerned that there is a lacuna in mandated care standards for patients treated privately by clinicians within the regulatory framework which gives rise to a risk of death.
” 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 Continue promoting College standards and guidance on safe surgical practice, multidisciplinary working and equivalent care standards across NHS and independent sectors.
Verbatim wording from the response “The College will draw the findings of this Prevention of Future Deaths report to the attention of relevant professional networks and stakeholders within the independent healthcare sector, including organisations involved in clinical governance and quality assurance. We will also continue to promote existing College standards and guidance relating to safe surgical practice, multidisciplinary working and equivalent standards of care across sectors.” Source location Response from Royal College of Surgeons
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulatory arrangements for implementing NICE guidance in independent practice fall outside the College’s role as a non-statutory regulator.
Verbatim wording from the response “Specifically, your report raises concerns regarding the variation in the implementation of NICE cancer pathway standards, including referral to specialist skin multidisciplinary teams (SSMDTs) between NHS and independent sector practice. The report also highlights broader questions regarding governance, accountability and the consistency of clinical standards across different healthcare settings.” Source location Response from Royal College of Surgeons
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5 Dec 2025 Man Yin ‘Anita’ Ng · Prevention of Future Deaths report Coventry
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Concerns raised 3 Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages View source Variation in the availability of neurointerventional procedures View source Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms View source
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Each statement is shown once, even when linked to more than one concern.
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Man Yin ‘Anita’ Ng · 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
Man Yin ‘Anita’ Ng attended hospital with a subarachnoid haemorrhage caused by an aneurysm. Her coiling procedure was delayed while staff sought an available neurointerventional catheter lab and anaesthetist; she suffered a re-rupture shortly before the procedure and died on 22 January 2025. The principal concern was that complex arrangements and unclear overall clinical responsibility for managing ruptured aneurysms may place patients at risk, particularly because of variation in access to neurointerventional procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Variation in the availability of neurointerventional procedures
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” 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 Provide access to the published credentialing process for non-radiologists undertaking thrombectomy training.
Verbatim wording from the response “Following this report, the College will work with the SBNS and BNVG to develop a position statement setting out recommendations for the management of the clinical care of SAH patients, and also for the provision of access to the recently published credentialing process for thrombectomy training for non-radiologists, which could allow neurosurgeons with a neurovascular interest to train in both endovascular and open surgical treatment to improve patient-centred decision-making.” Source location Response from Royal College of Surgeons
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a position statement with SBNS and BNVG recommending how clinical care for subarachnoid haemorrhage patients should be managed.
Verbatim wording from the response “Following this report, the College will work with the SBNS and BNVG to develop a position statement setting out recommendations for the management of the clinical care of SAH patients, and also for the provision of access to the recently published credentialing process for thrombectomy training for non-radiologists, which could allow neurosurgeons with a neurovascular interest to train in both endovascular and open surgical treatment to improve patient-centred decision-making.” Source location Response from Royal College of Surgeons
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Neurosurgeons are considered best placed to manage SAH patients across pre-treatment, treatment and post-treatment care.
Verbatim wording from the response “However, we consider that neurosurgeons are best positioned to manage these patients because they are trained to manage the full spectrum of SAH complications, including pre- and post-treatment challenges, regardless of whether the definitive intervention is surgical or endovascular. Neurosurgical team working patterns are also best placed to support continuity of care, which is crucial for these complex patients.” Source location Response from Royal College of Surgeons
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local multidisciplinary teams may determine how SAH services are delivered, provided neurosurgical and interventional neuroradiology expertise is included.
Verbatim wording from the response “The College recognises that effective decision-making within the multi-disciplinary team (MDT) is key and that any treatment strategy in patients with aneurysmal subarachnoid haemorrhage should be decided by teams with both surgical and endovascular expertise. The specific details of how this service should be delivered by the MDT may vary and can be decided locally provided there is sufficient input by both neurosurgeons and INR colleagues, leading to safe and effective treatment.” Source location Response from Royal College of Surgeons
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8 Oct 2025 William King · Prevention of Future Deaths report Milton Keynes
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Concerns raised 4 Inadequate explanation of NG tube risks and necessity to patients View source Failure to document consent discussions about NG tube treatment View source Failure to implement consent policy in practice View source Absence of clear responsibility for explaining NG tube necessity View source See 1 more concern
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William 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
William King died at Milton Keynes University Hospital on 26 January 2025 following an aspiration episode during preparation for emergency laparotomy for bowel obstruction. The principal concerns were inadequate explanation and documentation of the risks and necessity of a nasogastric tube, failure to implement the relevant consent policy, and unclear responsibility for ensuring this aspect of care was addressed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Inadequate explanation of NG tube risks and necessity to patients
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage . There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care.
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to document consent discussions about NG tube treatment
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor . Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case . The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care.
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement consent policy in practice
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice , suggesting a gap between policy and practice that may affect other patients . The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content .
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care.
I conclude that, since the policy was not followed despite being in place , there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Absence of clear responsibility for explaining NG tube necessity
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy . The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care .
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” 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 Maintain consent principles in the updated and published Good Surgical Practice core standards.
Verbatim wording from the response “• The same principles around the consent process are emphasised in our core standards document, Good Surgical Practice, which was recently updated and published in 2025.” Source location Response from Royal College of Surgeons of England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update consent guidance to reflect revised Good Surgical Practice.
Verbatim wording from the response “• Advice and guidance: We were concerned to read of the confusion between surgeons and anaesthetists in Billy’s care team around the responsibility for communicating the risks of not placing a nasogastric tube. Although our guidance is clear the surgeon discussing treatment with the patient has the responsibility for communicating the relevant associated risks and complications in the patient’s treatment, we appreciate that, in some cases, some aspects of anaesthetic consent are complex and may require an additional conversation. We are currently in the process of updating our consent guidance to take into account our recent revision of Good Surgical Practice, and we will seek to consult with colleagues at the Royal College of Anaesthetists for coordinated advice in this area.” Source location Response from Royal College of Surgeons of England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult the Royal College of Anaesthetists on coordinated advice for complex anaesthetic consent and risk communication.
Verbatim wording from the response “• Advice and guidance: We were concerned to read of the confusion between surgeons and anaesthetists in Billy’s care team around the responsibility for communicating the risks of not placing a nasogastric tube. Although our guidance is clear the surgeon discussing treatment with the patient has the responsibility for communicating the relevant associated risks and complications in the patient’s treatment, we appreciate that, in some cases, some aspects of anaesthetic consent are complex and may require an additional conversation. We are currently in the process of updating our consent guidance to take into account our recent revision of Good Surgical Practice, and we will seek to consult with colleagues at the Royal College of Anaesthetists for coordinated advice in this area.” Source location Response from Royal College of Surgeons of England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide consent guidance on supported decision-making, informed consent, treatment options, material risks and patient-specific communication.
Verbatim wording from the response “• The College has produced guidance on Consent: Supported Decision-Making which lays out the key principles that underpin the consent process. This guidance emphasises that for the patient’s consent to be considered informed, surgeons must be satisfied that the patient has received and understood full and sufficient information about the proposed treatment and its implications. This includes presenting the various treatment options and discussing their relative risks and benefits side by side. It makes clear that consent should be patient-specific, and that surgeons should communicate the risks that are material to the particular patient and their circumstances.” Source location Response from Royal College of Surgeons of England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult the GMC on practical consent tools and checklists supporting implementation of the consent guidance.
Verbatim wording from the response “• Implementation: We have recently consulted with the GMC on the development and publication of practical tools and checklists to assist in the implementation of our guidance on consent. We plan on publishing these additional tools alongside our updated guidance on consent over the coming year. We are also in the process of developing a brief e-learning module on consent based on our guidance which can be used by hospitals to train their teams locally.” Source location Response from Royal College of Surgeons of England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish practical consent tools and checklists alongside the updated consent guidance.
Verbatim wording from the response “• Implementation: We have recently consulted with the GMC on the development and publication of practical tools and checklists to assist in the implementation of our guidance on consent. We plan on publishing these additional tools alongside our updated guidance on consent over the coming year. We are also in the process of developing a brief e-learning module on consent based on our guidance which can be used by hospitals to train their teams locally.” Source location Response from Royal College of Surgeons of England
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a brief consent e-learning module for local hospital team training.
Verbatim wording from the response “• Implementation: We have recently consulted with the GMC on the development and publication of practical tools and checklists to assist in the implementation of our guidance on consent. We plan on publishing these additional tools alongside our updated guidance on consent over the coming year. We are also in the process of developing a brief e-learning module on consent based on our guidance which can be used by hospitals to train their teams locally.” Source location Response from Royal College of Surgeons of England
Open published response
23 Apr 2025 Lorraine Sandra Parker · Prevention of Future Deaths report Berkshire
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Concerns raised 2 Failure to take postoperative CRP results into account in discharge and scanning decisions View source Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery View source
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AI-generated summary
Lorraine Sandra 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
Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to take postoperative CRP results into account in discharge and scanning decisions
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario . I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan .
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing , as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise . Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact ACPGBI to support its assessment of guidance needs and dissemination of any resulting guidance or communications.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
Open published response
8 Nov 2024 Lacey May Brookman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to reach a diagnosis in an ill patient View source Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain View source Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain View source Unavailability of bedside or departmental ultrasound scanning for abdominal pain View source Failure to consider appendicitis in patients with abdominal pain View source Failure to use bedside or departmental ultrasound scanning for abdominal pain View source See 3 more concerns
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AI-generated summary
Lacey May Brookman · 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
Lacey May Brookman, aged 11, experienced more than a week of abdominal pain and related symptoms before retrocaecal appendicitis was diagnosed after perforation and abscess formation. She underwent surgery and developed severe complications, including coagulopathy, disseminated intravascular coagulation and multiorgan failure, and died on 4 June 2021. Concerns included difficulty recognising retrocaecal appendicitis, and the availability and use of abdominal ultrasound scanning and training for doctors considering the 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to reach a diagnosis in an ill patient
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain
Wider context from the report “2. Despite the slant of available literature, it was evident retrocaecal appendicitis presentation is not a rare presentation of either acute appendicitis or generalised abdominal pain (both common presenting features in the young)
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain
Wider context from the report “4. The training of doctors in considering the diagnosis as a possible differential to generalised abdominal pain.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider appendicitis in patients with abdominal pain
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to use bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” 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 an anonymised educational Surgical Safety vignette about the case in the specified surgical journals and disseminate it to a wide surgical audience.
Verbatim wording from the response “This case has been forwarded to the Programme Director of the Confidential Reporting System for Surgery (CORESS) and will be published as an anonymised educational Surgical Safety vignette in the Annals of the Royal College of Surgeons of England, and in Surgeons’ News, the Journal of the Royal College of Surgeons of Edinburgh, ensuring its dispersal to a wide surgical audience. The case will also be discussed with the Surgical Safety Lead of NHSE.” Source location Response from Royal College of Surgeons of England
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 Share the report with Specialty Advisory Committee Chairs for consideration in upcoming curriculum reviews.
Verbatim wording from the response “As you highlight, retrocaecal appendicitis is not a rare presentation. Within the postgraduate Intercollegiate Surgical Curriculum Programme, its diagnosis and management are addressed through the Core Surgery, Paediatric Surgery and General Surgery curricula, as part of the focus on acute appendicitis and acute abdominal conditions. The condition therefore forms part of the syllabus of the Intercollegiate MRCS and FRCS (Gen Surg) & (Paed Surg) examinations. While we believe current curricula coverage is adequate, we recognise the importance of continually reviewing our curricula and we have shared your report with our Specialty Advisory Committee Chairs for their consideration during upcoming curricula reviews.” Source location Response from Royal College of Surgeons of England
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 CCRISP course content to determine whether it should explicitly refer to retrocaecal appendicitis.
Verbatim wording from the response “Our education team has also reviewed your report and they are now exploring whether we can explicitly refer to retrocaecal appendicitis. Specifically, we are reviewing the content of the Care of the Critically Ill Surgical Patient (CCRISP) and the Clinical Skills in Emergency Surgery courses. The updated version of CCRISP is scheduled for launch in 2025, while the Clinical Skills in Emergency Surgery course is in the early stages of redevelopment.” Source location Response from Royal College of Surgeons of England
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 Redevelop the Clinical Skills in Emergency Surgery course while reviewing whether to explicitly refer to retrocaecal appendicitis.
Verbatim wording from the response “Our education team has also reviewed your report and they are now exploring whether we can explicitly refer to retrocaecal appendicitis. Specifically, we are reviewing the content of the Care of the Critically Ill Surgical Patient (CCRISP) and the Clinical Skills in Emergency Surgery courses. The updated version of CCRISP is scheduled for launch in 2025, while the Clinical Skills in Emergency Surgery course is in the early stages of redevelopment.” Source location Response from Royal College of Surgeons of England
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 Launch the updated CCRISP course version incorporating the completed content review.
Verbatim wording from the response “Our education team has also reviewed your report and they are now exploring whether we can explicitly refer to retrocaecal appendicitis. Specifically, we are reviewing the content of the Care of the Critically Ill Surgical Patient (CCRISP) and the Clinical Skills in Emergency Surgery courses. The updated version of CCRISP is scheduled for launch in 2025, while the Clinical Skills in Emergency Surgery course is in the early stages of redevelopment.” Source location Response from Royal College of Surgeons of England
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 Local Trusts and ICBs determine out-of-hours paediatric radiology service availability and quality; the Royal College of Radiologists may provide advice.
Verbatim wording from the response “The out of hours provision of paediatric radiology services, particularly ultrasound, is a service availability and quality matter, determined by local Trusts/ICB's. It is not provided by surgeons in any point of their training or curriculum, and advice from the Royal College of Radiologists might be sought. An NCEPOD review may also help determine the current risks and requirements for a safe paediatric radiology service going forwards.” Source location Response from Royal College of Surgeons of England
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 Current surgical curricula adequately cover retrocaecal appendicitis, so no additional curriculum change is considered necessary beyond ongoing review.
Verbatim wording from the response “As you highlight, retrocaecal appendicitis is not a rare presentation. Within the postgraduate Intercollegiate Surgical Curriculum Programme, its diagnosis and management are addressed through the Core Surgery, Paediatric Surgery and General Surgery curricula, as part of the focus on acute appendicitis and acute abdominal conditions. The condition therefore forms part of the syllabus of the Intercollegiate MRCS and FRCS (Gen Surg) & (Paed Surg) examinations. While we believe current curricula coverage is adequate, we recognise the importance of continually reviewing our curricula and we have shared your report with our Specialty Advisory Committee Chairs for their consideration during upcoming curricula reviews.” Source location Response from Royal College of Surgeons of England
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Surgeons of England; 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 Surgeons of England; 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 Surgeons of England; 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 Surgeons of England; 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 Surgeons of England; 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
Concerns raised 1 Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times 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
Tracy Gambrill · 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
Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.
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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position.
I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation.
” Open source report
7 Jan 2022 Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to use targeted factual communication between surgical and anaesthetic teams during surgery View source Failure to communicate a surgeon's reasons for leaving surgery to the surgical team View source Failure to effectively monitor when a surgeon leaves theatre View source Lack of a system to assess the appropriateness of a surgeon leaving surgery View source Lack of a formal preoperative risk assessment tool requirement View source Failure to record a surgeon's early departure in the surgical notes View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Surekha Pandharinath Shivalkar · 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
Mrs Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.
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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to use targeted factual communication between surgical and anaesthetic teams during surgery
Wider context from the report “2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient’s welfare passed between the two teams but no targeted questions requiring clear factual responses were asked . Had such questions been put, a different outcome may have arisen.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate a surgeon's reasons for leaving surgery to the surgical team
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team , neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively monitor when a surgeon leaves theatre
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre .
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to assess the appropriateness of a surgeon leaving surgery
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate , or to effectively monitor when a surgeon leaves theatre.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal preoperative risk assessment tool requirement
Wider context from the report “1. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Health NHS Trust since 2018, there remains no requirement to utilise such a 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to record a surgeon's early departure in the surgical notes
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure . The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.
” Open source report
1 Dec 2020 Peter James Michael Unsworth · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to document received specialist advice and confirm understanding View source Failure to confirm and record specialist advice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter James Michael Unsworth · 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
Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.
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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to document received specialist advice and confirm understanding
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm and record specialist advice
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” 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 Maintain guidance requiring accurate records, detailed follow-up notes, discharge summaries, and prompt sharing of relevant postoperative information.
Verbatim wording from the response “The Royal College of Surgeons (England) is clear that information sharing is an essential part of the provision of safe and effective care. The need for effective and appropriate information sharing is a key part of our core guidance document for surgeons, Good Surgical Practice, and underpins our series of associated resources, and specifically our Good Practice Guides.” Source location Response-from-RCS-England-2020-0267-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 Endorse and support the Professional Record Standards Body’s standards for the structure and content of health and care records.
Verbatim wording from the response “The RCS also has engaged with the development of – and endorses – the detailed advice published by the Professional Record Standards Body and specifically their Standards for the Structure and Content of Health and Care Records.” Source location Response-from-RCS-England-2020-0267-Redacted
Open published response
25 Jan 2019 Stephen Pettitt · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 2 Lack of national guidelines for training required for new interventional procedure programmes View source Lack of national guidelines for implementation of new interventional procedure programmes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Pettitt · 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
Stephen Pettitt died following complications during a robotically assisted mitral valve operation on 23 February 2015, the first such operation at the Freeman Hospital and the first performed by the primary surgeon. The operation was prolonged, with a cross-clamp time exceeding six hours, and the report identifies concerns about the absence of guidance on training, proctoring, and patient information for new interventional procedures. The Coroner considered that these issues had wider national implications and that appropriate national guidelines should be considered.
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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for training required for new interventional procedure programmes
Wider context from the report “The Coroner considers however there are wider national implications and that consideration to the creation of appropriate national guidelines in respect of the implementation of any New Interventional Procedure programme and the training required in respect thereof should be 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for implementation of new interventional procedure programmes
Wider context from the report “The Coroner considers however there are wider national implications and that consideration to the creation of appropriate national guidelines in respect of the implementation of any New Interventional Procedure programme and the training required in respect thereof should be considered.
” 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 a Good Practice Guide on Surgical Innovation, New Techniques and Technologies, including training, mentorship and clinical governance guidance.
Verbatim wording from the response “In the last few years, the RCS has been undertaking work to understand the impact of innovation and technology, such as robotic surgery, on patients, the surgical workforce and the healthcare system. In October 2017, we established the independent Commission on the Future of Surgery to identify the likely advances in medicine and technology in the next twenty years. The Commission published its report in December 2018, which outlined how these technological changes may affect the delivery of surgical care. Following on from this, we will shortly be publishing a Good Practice Guide on Surgical Innovation, New Techniques and Technologies. This will contain a chapter on ‘training in new techniques’ that will state:” Source location 2019-0037-Response-by-Royal-College-of-Surgeons
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 Publish and maintain Good Surgical Practice guidance covering the introduction of new surgical techniques.
Verbatim wording from the response “In 2014, we published Good Surgical Practice, a baseline of clear and assessable standards for individual surgeons and their practice, which contains a chapter on the ‘introduction of new techniques’. The guidance seeks to exemplify the standards required of all doctors by the GMC in the context of surgery. In relation to Mr Pettitt’s robotically assisted mitral valve operation, the guidance states:” Source location 2019-0037-Response-by-Royal-College-of-Surgeons
Open published response
Concerns raised 1 Insufficient systems for collating an appropriate antibiotic history for patients coming from a distance 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
Mrs Kay Morrison · 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
Mrs Kay Morrison underwent necessary surgery at the Royal Hallamshire Hospital on 11 June 2015, developed severe bacterial and fungal infections, and died of sepsis on 21 June 2015. The principal concern was that no proper antibiotic history was obtained, amid insufficient systems for collating such histories, resulting in antibiotics being prescribed for prophylaxis and treatment that were not effective for their intended purpose.
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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Insufficient systems for collating an appropriate antibiotic history for patients coming from a distance
Wider context from the report “a) The evidence showed that there was insufficient system to ensure the collation of an appropriate antibiotic history . The Hospital Trust concerned avows that it has rectified this issue but it seems likely that many other hospitals may be in the same position if patients are coming from a distance .
” 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 Surgeons of England; 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 Surgeons of England; 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
16 Jun 2017 Mrs Macrae · Prevention of Future Deaths report Northamptonshire
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Concerns raised 2 Failure to seek attendance by the attending spinal surgeon for postoperative instability View source Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery View source
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Macrae · 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
Mrs Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.
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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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to seek attendance by the attending spinal surgeon for postoperative instability
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend . Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability.
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability .
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery .
” Open source report
24 Mar 2014 Phyllis Barnes · Prevention of Future Deaths report Surrey
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Concerns raised 4 Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery View source Failure of visiting general practitioners to appreciate the seriousness of patients’ conditions View source Lack of formal communication opportunities for patients’ relatives to report patients’ conditions to primary care clinicians View source Unreliable promised telephone follow-up View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Phyllis Barnes · 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
Phyllis Barnes underwent elective laparoscopic anterior resection and was discharged home, but developed persistent vomiting and became increasingly unwell. She was later readmitted with an anastomotic leak and died from complications. Concerns included delayed recognition of the seriousness of her symptoms, a superficial nurse-led telephone consultation with uncertain follow-up, and a lack of formal communication with her daughter.
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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery
Wider context from the report “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Failure of visiting general practitioners to appreciate the seriousness of patients’ conditions
Wider context from the report “1. Failure of visiting General Practitioner to appreciate the seriousness of Mrs Barnes condition in view of her recent operation and persistent 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Lack of formal communication opportunities for patients’ relatives to report patients’ conditions to primary care clinicians
Wider context from the report “3. There was no formal communication or opportunity for Mrs Barnes’s daughter to relate her mother’s condition to the GP or the Nurse Practitioner
” 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 Surgeons of England; that does not assign responsibility.
PFD Monitor interpretation Unreliable promised telephone follow-up
Wider context from the report “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations