Concerns raised 1 Failure to address failings identified at inquest 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
JANET MARY TRIPP · 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
Janet Mary Tripp died from frailty of old age and an ischaemic right foot caused by peripheral vascular disease. An avoidable pressure sore developed during a seven-hour stay in the Royal Cornwall Hospital discharge lounge and more than minimally contributed to her death. The report identified failures including a lack of care rounds, inadequate repositioning, absent risk assessment, and insufficient handover information; there was insufficient evidence that these failings had been addressed by the hospital.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to address failings identified at inquest
Wider context from the report “There was insufficient evidence before the court to indicate that the above failings found at Inquest had been addressed by the hospital .
” Open source report
Concerns raised 3 Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English View source Failure to establish the contents of an infant’s bottle feed View source Lack of culturally informed professional curiosity in infant feeding assessment 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
Izzah Fatima Ali · 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
Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal visits.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved , contrary to 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the contents of an infant’s bottle feed
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry . In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle . It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact .
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle .
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of culturally informed professional curiosity in infant feeding assessment
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices : while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries , for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity .
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” Open source report
Concerns raised 1 Failure to ensure timely prescription of usual medication for late and unexpected admissions 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
Tracey Oldfield · 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
Tracey Oldfield underwent an elective fistula revision procedure on 17 October 2024 and was admitted after developing low oxygen saturations and low blood sugars. She became drowsy and unresponsive after receiving opiate pain relief that was contraindicated in end-stage renal failure, while her CPAP device was unavailable and there was no senior medical review. She suffered a cardiac arrest, developed a hypoxic brain injury, and died on 24 October 2024. A continuing concern was the timely prescription of patients’ usual medication after unexpected admission, including appropriate pain relief.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely prescription of usual medication for late and unexpected admissions
Wider context from the report “One point that did not appear to have been fully resolved , however, centred on the need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion .
On the facts of this case, Tracey was prescribed insulin when the family informed clinical staff she had a diagnosis of diabetes. Her pain relief was not prescribed at the same time , however, and as she became more uncomfortable after the nerve block used intra-operatively wore off, this resulted in her being prescribed opiates (inappropriately) rather than her usual Gabapentin.
There was debate at the inquest as to who would be best placed to prepare the prescription and when . Matron ████████ thought it could be done by an anaesthetist who would be reviewing the patient pre-operatively in any event. ████████ (Head of Patient Safety) felt it could be better done by a junior doctor when a patient was admitted and clerked in. On the facts of this case, Tracey was not seen by a junior doctor (other than to have an insulin prescription) and was not formally clerked in.
” Open source report
Concerns raised 2 Failure to establish an appropriate admission pathway for worsening patients in the renal unit View source Lack of implemented standard operating procedures for worsening patients in the renal unit 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
JASON JAMES CLEMENS · 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
Jason James Clemens died on 23 March 2024 after a seven-hour delay in administering antibiotics prescribed for immediate use following a medical episode at the renal unit. The report identified four missed opportunities to administer the antibiotics and stated that the delay likely hastened his death and more than minimally contributed to his cause of death. It also raised concerns about the absence of implemented procedures for managing worsening renal-unit patients and uncertainty about the appropriate admission 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish an appropriate admission pathway for worsening patients in the renal unit
Wider context from the report “The hospital accepted that there were failings that contributed to Jason’s death. Measures to address those failings had not been fully implemented at the date of the Inquest. There were no applicable standard operating procedures for worsening patients in the renal unit at the date of Jason’s death and none had been implemented by the date of the inquest. Jason died on 23 March 2024. The inquest was held on 5 June 2025.
The court was told that the standard operating procedures are still being drafted in relation to identifying the appropriate pathway for the admission of worsening patients in the renal unit . The clinicians were undecided on applicable processes including whether the emergency department should be the default pathway.
The court found on the evidence that moving worsening patients out of the renal unit and onto in-patient facilities is imperative and should be done at the first available opportunity. Such action would reduce the risks of medication and treatment errors and delays such as that which occurred in Jason’s case. Delays due to uncertainties about appropriate pathways raises risks to patients who require the specialist treatment available on in-patient facilities.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of implemented standard operating procedures for worsening patients in the renal unit
Wider context from the report “The hospital accepted that there were failings that contributed to Jason’s death. Measures to address those failings had not been fully implemented at the date of the Inquest. There were no applicable standard operating procedures for worsening patients in the renal unit at the date of Jason’s death and none had been implemented by the date of the inquest. Jason died on 23 March 2024. The inquest was held on 5 June 2025.
The court was told that the standard operating procedures are still being drafted in relation to identifying the appropriate pathway for the admission of worsening patients in the renal unit. The clinicians were undecided on applicable processes including whether the emergency department should be the default pathway.
The court found on the evidence that moving worsening patients out of the renal unit and onto in-patient facilities is imperative and should be done at the first available opportunity. Such action would reduce the risks of medication and treatment errors and delays such as that which occurred in Jason’s case. Delays due to uncertainties about appropriate pathways raises risks to patients who require the specialist treatment available on in-patient facilities.
” Open source report
Concerns raised 3 Failure to recognise when patients are receiving Aspirin only View source Failure to act on recognised medication oversights View source Lack of proper induction for locum clinicians undertaking extended service cover 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
David Charles Martin · 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
David Charles Martin, an 83-year-old man with progressive heart failure, was admitted to hospital, underwent PCI, collapsed later that day, and died in hospital on 17 September 2022. The principal concerns were inadequate induction for a locum doctor unfamiliar with the Trust’s DAPT policy and multiple missed opportunities to identify and act on the fact that he had been prescribed Aspirin only.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when patients are receiving Aspirin only
Wider context from the report “2) There were multiple opportunities where the fact Mr Martin was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recognised medication oversights
Wider context from the report “2) There were multiple opportunities where the fact Mr Martin was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of proper induction for locum clinicians undertaking extended service cover
Wider context from the report “1) The inquest heard evidence that the locum SHO involved in the care of Mr Martin was 9 days into a 3-4 month period of cover. She had not received any cardiology induction and was unaware of the Trust DAPT policy regarding PCI patients. It was accepted that while it was a challenge to ensure locums who covered 1-2 shifts had a thorough induction, where one was being asked to work in the service for an extended period of time, it was necessary that there was a proper induction process . The inquest heard changes have already been made in this regard.
” Open source report
Concerns raised 4 Failure to provide risk-appropriate thrombosis prophylaxis after elective knee replacement View source Failure to ensure clinicians access accurate thrombosis prophylaxis guidance View source Failure to identify the prescribing doctor and record prescribing decision-making View source Routine prescription of aspirin to high-risk patients regardless of prophylaxis guidance 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
Julie Louise Hancock · 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
Julie Louise Hancock underwent a right total knee replacement on 2 March 2022, was discharged on 5 March 2022, and died at home on 28 March 2022. Her post-mortem cause of death was pulmonary embolus due to deep vein thrombosis, with immobility following the knee replacement. The concerns included apparent prescription of low-risk thrombosis prophylaxis despite her being assessed as high risk, an unidentified doctor’s prescription of dalteparin that was stopped after one dose, and possible discrepancies between summary and full thrombosis-prevention 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide risk-appropriate thrombosis prophylaxis after elective knee replacement
Wider context from the report “I enclose the bundle of evidence.
At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin ████████ for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban ████████ once daily for 14 days
As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.
At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:
Low risk – Aspirin ████████ daily for 14 days
High Risk – Rivaroxaban ████████ daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)
████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.
█ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance.
████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.
I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinicians access accurate thrombosis prophylaxis guidance
Wider context from the report “I enclose the bundle of evidence.
At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin ████████ for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban ████████ once daily for 14 days
As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.
At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:
Low risk – Aspirin ████████ daily for 14 days
High Risk – Rivaroxaban ████████ daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)
████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.
█ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance .
████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.
I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the prescribing doctor and record prescribing decision-making
Wider context from the report “I enclose the bundle of evidence.
At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin ████████ for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban ████████ once daily for 14 days
As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.
At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:
Low risk – Aspirin ████████ daily for 14 days
High Risk – Rivaroxaban ████████ daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)
████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.
█ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance.
████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.
I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Routine prescription of aspirin to high-risk patients regardless of prophylaxis guidance
Wider context from the report “I enclose the bundle of evidence.
At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin ████████ for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban ████████ once daily for 14 days
As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.
At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:
Low risk – Aspirin ████████ daily for 14 days
High Risk – Rivaroxaban ████████ daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)
████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.
█ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance.
████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022 . This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.
I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.
” Open source report
Concerns raised 5 Lack of continuity in medical or nursing care for patients staying on AMU longer than usual View source Lack of clarity about when NIV can be offered to admitted patients View source Failure to use food and fluid charts to monitor hydration and calorific intake View source Failure to recognise deterioration in a patient's presentation promptly View source Failure to identify admitted patients with a respiratory component and bring them to the attention of the respiratory team 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
Felice Eileen Grace Banfield · 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
Felice Eileen Grace Banfield was admitted with a painful knee and required non-invasive ventilation, but there was a lack of clarity about where and when this could be provided. She was not brought to the attention of respiratory clinicians, deteriorated with mixed respiratory and metabolic acidosis and an acute kidney injury, and died despite treatment. The principal concerns were failures concerning access to non-invasive ventilation, recognition of respiratory risk and deterioration, and provision and monitoring of adequate food, fluids and continuity of 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in medical or nursing care for patients staying on AMU longer than usual
Wider context from the report “A failure to recognise a deterioration in the presentation of a patient which could have triggered a request for repeat bloods and revealed the worsening acidosis before an AKI developed. There appear at least two elements to this:
i) the use of food and fluid charts to make sure a patient is not becoming dehydrated and is having adequate calorific intake;
ii) for patients who stay on AMU longer than usual, ensuring there is some continuity in medical or nursing care , so a deterioration in presentation can be recognised promptly . Would there be value, for example, in requiring a patient who is on AMU for longer than say, 48 hours, to become the responsibility of a single, named consultant who will be responsible for regular review starting at the 48 hour mark?
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when NIV can be offered to admitted patients
Wider context from the report “A lack of clarity about if and when NIV can be offered to admitted patients.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use food and fluid charts to monitor hydration and calorific intake
Wider context from the report “A failure to recognise a deterioration in the presentation of a patient which could have triggered a request for repeat bloods and revealed the worsening acidosis before an AKI developed. There appear at least two elements to this:
i) the use of food and fluid charts to make sure a patient is not becoming dehydrated and is having adequate calorific intake ;
ii) for patients who stay on AMU longer than usual, ensuring there is some continuity in medical or nursing care, so a deterioration in presentation can be recognised promptly. Would there be value, for example, in requiring a patient who is on AMU for longer than say, 48 hours, to become the responsibility of a single, named consultant who will be responsible for regular review starting at the 48 hour mark?
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in a patient's presentation promptly
Wider context from the report “A failure to recognise a deterioration in the presentation of a patient which could have triggered a request for repeat bloods and revealed the worsening acidosis before an AKI developed. There appear at least two elements to this:
i) the use of food and fluid charts to make sure a patient is not becoming dehydrated and is having adequate calorific intake;
ii) for patients who stay on AMU longer than usual, ensuring there is some continuity in medical or nursing care, so a deterioration in presentation can be recognised promptly. Would there be value, for example, in requiring a patient who is on AMU for longer than say, 48 hours, to become the responsibility of a single, named consultant who will be responsible for regular review starting at the 48 hour mark?
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify admitted patients with a respiratory component and bring them to the attention of the respiratory team
Wider context from the report “A patient admitted into RCHT with a respiratory element to her underlying condition was not brought to the attention of the respiratory team . The presenting complaint was not of a respiratory nature and so the challenge appears to be to identify those patients with multiple co-morbidities, one of which has a respiratory component, particularly where the patient is not on a respiratory ward .
” 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 Monitor Trustwide compliance with MUST scoring and food and hydration charts through AMaT and address hotspots.
Verbatim wording from the response “Trust wide compliance with MUST scoring, Food and Hydration Charts is monitored monthly on the Audit Management and Tracking (AMaT) system. The AMaT system highlights any hotspots for needing additional support with training and learning that can be supported by the Lead for Quality, Safety and Innovation and Corporate Nursing Team. AMU has not triggered as a hotspot of concern which would suggest the action being taken by the Matron and the sharing of the safety briefing has been effective.” Source location Response from Royal Cornwall Hospital
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 Implement early-morning bedside review of AMU patients to identify deterioration and refer patients to appropriate clinical teams.
Verbatim wording from the response “The improvements also include ensuring that all AMU patients are reviewed early each morning at the bedside, identifying patients who are deteriorating and referring them to the correct clinical teams. In addition the project team will also review and update existing policies and standard operating procedures (SOPs) for all admitting areas to ensure they are up to date and support the principle of the right patient in the right bed at the right time.” Source location Response from Royal Cornwall Hospital
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 Cascade a safety briefing to relevant AMU staff on using food and fluid charts for vulnerable patients.
Verbatim wording from the response “Following the local investigation completed by the Trust, AMU cascaded a safety briefing to all relevant staff regarding the appropriate use of fluid and food charts in vulnerable patients, highlighting the learning identified in the investigation.” Source location Response from Royal Cornwall Hospital
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 Share the approved revised NIV policy with key staff, relevant wards and Trustwide staff.
Verbatim wording from the response “The Non-Invasive Ventilation Use in Patients with Acute Hypercapnic Respiratory Failure Standard Operating Policy (SOP) is currently in the process of being reviewed, however the above detail is also in the current live version. The current version of the SOP has been shared with staff on AMU which gives clarity of when and where NIV can be offered to patients, both those who are stable and those admitted acutely. Once the revised SOP has been signed off, this will be shared with key staff and wards and a communication circulated Trustwide to ensure that staff know about the revised SOP, the key changes and how to access it.” Source location Response from Royal Cornwall Hospital
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 and revise the NIV use standard operating policy.
Verbatim wording from the response “The Non-Invasive Ventilation Use in Patients with Acute Hypercapnic Respiratory Failure Standard Operating Policy (SOP) is currently in the process of being reviewed, however the above detail is also in the current live version. The current version of the SOP has been shared with staff on AMU which gives clarity of when and where NIV can be offered to patients, both those who are stable and those admitted acutely. Once the revised SOP has been signed off, this will be shared with key staff and wards and a communication circulated Trustwide to ensure that staff know about the revised SOP, the key changes and how to access it.” Source location Response from Royal Cornwall Hospital
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 Implement a band 6 AMU link nurse role for nutrition and hydration quality improvement.
Verbatim wording from the response “AMU have also implemented a band 6 link nurse for nutrition and hydration on the ward. This individual liaises with the dietitians and therapists as part of quality improvement. There is a study session on the ward booked for the 4th of June 2023 where nutrition and hydration will be covered.” Source location Response from Royal Cornwall Hospital
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 Use PAS alerts and the RADAR report to identify NIV patients admitted outside respiratory wards.
Verbatim wording from the response “Based on the learning from this case, where patients whose primary reason for admission is not a respiratory element, but because of the specialist care some respiratory patients may require, for example, as in this case NIV; it was decided that it would be useful to have a way of quickly identifying these patients to the respiratory clinical nurse specialist team when the patients are not accommodated on a respiratory ward.” Source location Response from Royal Cornwall Hospital
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 Have Respiratory CNS staff review the RADAR report daily, contact identified wards and offer support.
Verbatim wording from the response “The report in RADAR has been shared with the Respiratory Matron and Respiratory Clinical Nurse Specialists (CNS). The expectation of the Respiratory CNS team is that they will review the RADAR page daily, contact the ward where the patient has been identified as admitted and offer any support that may be required, they will also ensure the ward has the contact details of the CNS so that they can be contacted if there is any need for their input.” Source location Response from Royal Cornwall Hospital
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 Deliver the scheduled AMU study session covering nutrition and hydration.
Verbatim wording from the response “AMU have also implemented a band 6 link nurse for nutrition and hydration on the ward. This individual liaises with the dietitians and therapists as part of quality improvement. There is a study session on the ward booked for the 4th of June 2023 where nutrition and hydration will be covered.” Source location Response from Royal Cornwall Hospital
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 current NIV policy with AMU staff to clarify when and where NIV can be offered.
Verbatim wording from the response “The Non-Invasive Ventilation Use in Patients with Acute Hypercapnic Respiratory Failure Standard Operating Policy (SOP) is currently in the process of being reviewed, however the above detail is also in the current live version. The current version of the SOP has been shared with staff on AMU which gives clarity of when and where NIV can be offered to patients, both those who are stable and those admitted acutely. Once the revised SOP has been signed off, this will be shared with key staff and wards and a communication circulated Trustwide to ensure that staff know about the revised SOP, the key changes and how to access it.” Source location Response from Royal Cornwall Hospital
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 current NIV policy provides sufficient clarity about when and where NIV can be offered to admitted patients.
Verbatim wording from the response “If a patient is admitted to RCHT now, usually on home NIV and stable, and can manage their own mask and ventilator as they would at home, they can be managed on any medical ward. There would only be a concern if the patient is positive for COVID-19 or flu and then they would need to be accommodated in a side room. However, if patients on long term domiciliary NIV are admitted acutely and are ventilator dependent (i.e. requiring treatment >15 hours per day), they would be managed in Wellington D Bay or Critical Care irrespective of their presenting complaint.” Source location Response from Royal Cornwall Hospital
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 Patients without concerns about a known respiratory co-morbidity need not be managed on a respiratory ward; existing referral arrangements apply if concerns arise.
Verbatim wording from the response “Not every patient presenting to the hospital with known co-morbidities will need to be cared for on the speciality ward for their known co-morbidity. If there are no concerns related to their underlying condition, they would be cared for on the appropriate ward for their primary presenting issue. If during the admission the underlying condition did give cause for concern, the patient would be referred to the appropriate speciality via the Maxims system. There is a space on the referral to leave your contact details and if for any reason the referral is rejected, the rejecting clinician can notify the referrer if these details have been completed.” Source location Response from Royal Cornwall Hospital
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 A single named consultant for AMU patients staying over 48 hours is not adopted because existing speciality visiting consultant arrangements provide speciality care.
Verbatim wording from the response “ii) for patients who stay on AMU longer than usual, ensuring there is some continuity in medical or nursing care, so a deterioration in presentation can be recognised promptly. Would there be value, for example, in requiring a patient who is on AMU for longer than say, 48 hours, to become the responsibility of a single, named consultant who will be responsible for regular review starting at the 48 hour mark?” Source location Response from Royal Cornwall Hospital
Open published response
Concerns raised 4 Delays or omissions in the administration of prescribed Parkinson’s medication View source Failure of ward staff to listen to family concerns View source Delays in the administration of antibiotics View source Lack of cleanliness and failure to change soiled bedding and clothes 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
Raymond Claude Woodhouse · 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
Raymond Claude Woodhouse had severe Parkinson’s disease and underwent a total knee replacement, after which he developed infections in his elbow and knee and died on 11 February 2019. Concerns included difficulties obtaining staff attention, poor cleanliness, a potential delay in antibiotics, and multiple late or omitted doses of prescribed Parkinson’s medication.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays or omissions in the administration of prescribed Parkinson’s medication
Wider context from the report “iv) Delays or omissions of prescribed Parkinson’s medication. Matron ████████ had reviewed the nursing records. She accepted in evidence that there were ‘multiple’ occasions when medication was given late and three occasions when it was not given at all. She conceded nursing standards had fallen below what could reasonably be expected.
The inquest was told this is a national problem coming out of the difficulties caused where a patient needs time-specific medication that falls outside traditional ward times for the administration of medication.
I was also informed that a business case has been prepared for consideration by the Board for the appointment of a specialist Parkinson’s nurse and pharmacist. It was not known whether the case had been accepted and, if so, when it will be taken forward.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of ward staff to listen to family concerns
Wider context from the report “i) The family complained they were unable to get staff on Karenza ward to listen to them. It was accepted in evidence that, at the time, there were staffing difficulties on the ward that have since been addressed.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in the administration of antibiotics
Wider context from the report “iii) Potential delay in the administration of antibiotics. In evidence, Dr ████████ accepted that with the benefit of hindsight this was the case. While it was not causative of the death it was possible this had resulted in an avoidable wash-out in 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of cleanliness and failure to change soiled bedding and clothes
Wider context from the report “ii) A lack of cleanliness with Mr Woodhouse being left in soiled bedding and clothes. It was not possible at inquest to come to a view that this was the cause of the infections in the knee and/or elbow.
” Open source report
Concerns raised 2 Unavailability of timely critical care haemofiltration View source Failure to undertake contingency planning between treating clinicians and specialist critical care team 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
Margaret Erskin Hare Wakefield · 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
Margaret Wakefield, who had severe heart and renal disease, deteriorated after a high-risk cardiac procedure and died following a cardiac arrest on 5 February 2016. The report identified concerns about the lack of timely haemofiltration and the need for improved access and contingency planning for critically ill patients requiring it.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely critical care haemofiltration
Wider context from the report “Margaret Wakefield suffered from unstable mental health which on occasions meant she had lack of insight into her medical needs. It was recognised by both the Cardiac Surgeon and Renal Consultant that she was very unwell, the procedure was high risk and that she would require dialysis and that Critical Care haemofiltration may be required. Mrs Wakefield deteriorated quickly and when a request for haemofiltration (which was necessary and potentially lifesaving) was made it was not available in a timely way . The lack of haemofiltration resulted in further deterioration and death occurred before the facility could be made available.
The Consultant Surgeon and Renal Consultant both raised concerns as to the lack of haemofiltration for a patient with chronic renal disease following high risk heart procedure in a timely way , and the need for improved access to timely haemofiltration and contingency planning between the treating clinicians and Specialist critical care 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake contingency planning between treating clinicians and specialist critical care team
Wider context from the report “Margaret Wakefield suffered from unstable mental health which on occasions meant she had lack of insight into her medical needs. It was recognised by both the Cardiac Surgeon and Renal Consultant that she was very unwell, the procedure was high risk and that she would require dialysis and that Critical Care haemofiltration may be required. Mrs Wakefield deteriorated quickly and when a request for haemofiltration (which was necessary and potentially lifesaving) was made it was not available in a timely way. The lack of haemofiltration resulted in further deterioration and death occurred before the facility could be made available.
The Consultant Surgeon and Renal Consultant both raised concerns as to the lack of haemofiltration for a patient with chronic renal disease following high risk heart procedure in a timely way, and the need for improved access to timely haemofiltration and contingency planning between the treating clinicians and Specialist critical care team .
” Open source report
Concerns raised 14 Inappropriate RCHT SI and SOM View source Failure to identify red flag signs of neonatal sepsis View source Unavailability and non-use of standard physiological observation equipment for mothers and babies View source Failure to undertake and record routine physiological observations of mothers and babies View source Core midwifery paperwork failing to prompt routine physiological assessments View source Failure of neonatal infection guidelines to be known and consistent with NICE guidance View source Failure to formally record Maternity Helpline calls and outcomes View source Use of a single birth-weight threshold in hypoglycaemic guidance View source Failure to complete NEWS on all babies View source Delays in full assessment of labour progress View source Insufficient systemic, rigorous and regular neonatal sepsis training View source Maternity Helpline triage by unregistered, inadequately trained and unqualified staff View source Unavailability of centile charts in handheld maternity records View source Failure to undertake and record capillary refill time in suspected neonatal sepsis View source See 11 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
Charlie Mark Jermyn · 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
Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Inappropriate RCHT SI and SOM
Wider context from the report “9. The Expert Midwife noted that RCHT SI and SOM were not appropriate and been identified in the most recent LSA report on the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify red flag signs of neonatal sepsis
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability and non-use of standard physiological observation equipment for mothers and babies
Wider context from the report “4. All Community Midwives should be provided with standard equipment to include, ear thermometers, stethoscopes, blood sugar testing and SATS monitors and these should be used as routine practice to make routine observations on mother and baby .
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and record routine physiological observations of mothers and babies
Wider context from the report “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives . This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Core midwifery paperwork failing to prompt routine physiological assessments
Wider context from the report “3. The Royal Cornwall Hospital Trust core midwifery paperwork does not meet best practice or NICE guidelines and does not prompt midwives to undertake routine physiological assessments .
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatal infection guidelines to be known and consistent with NICE guidance
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record Maternity Helpline calls and outcomes
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff, who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Use of a single birth-weight threshold in hypoglycaemic guidance
Wider context from the report “6. The Expert Midwife advised that the use of a single birth weight in the Trusts hypoglycaemic guidance (at risk at 2.5 kg) was not best practice and suggested the use of three weights: pre term, term, and late weight.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete NEWS on all babies
Wider context from the report “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives. This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies .
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in full assessment of labour progress
Wider context from the report “1. The Delay of over 5 hours, in full assessment of ████████ labour progress in the Day Assessment Unit at Royal Cornwall Hospital on the 8th/9th May 2015 was unacceptable (systemic failing).
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient systemic, rigorous and regular neonatal sepsis training
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area . The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Maternity Helpline triage by unregistered, inadequately trained and unqualified staff
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff , who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of centile charts in handheld maternity records
Wider context from the report “5. There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at 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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and record capillary refill time in suspected neonatal sepsis
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis .
” Open source report
16 Jun 2014 Mrs Care · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1 Failure to establish how patient trauma was sustained during hoist transfers 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 Care · 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 Care, an 86-year-old woman with poor mobility, was transferred to Helston Hospital for rehabilitation after treatment at Treliske and died there on 12 October 2013 after rapidly deteriorating. Extensive bruising and a soft tissue haematoma were found, with the haematoma recorded as contributory to her death; the inquest found it was more likely than not that trauma caused the bruising during her stay at the Royal Cornwall Hospital, but its precise cause was not established. The report also raises concerns that an Allow Natural Death Order was not communicated to the family and that their calls about the bruising were not returned.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish how patient trauma was sustained during hoist transfers
Wider context from the report “At inquest I found as a matter of fact that it was more likely than not that trauma caused the extensive bruising seen on Mrs Care’s hip and abdomen at post-mortem. I further found that it was more likely than not that this trauma was sustained during Mrs Care’s stay in the Royal Cornwall Hospital.
Evidence was read out at inquest that nothing untoward happened during the ambulance transfer. The bruising itself was discovered at the time of Mrs Care’s admission into Helston Community Hospital.
I was not able to offer the family an explanation at inquest as to how this trauma had been sustained. That is plainly undesirable and it is for this reason that I write to bring this matter to your attention. You will understand that the pathologist found the extensive soft tissue haematoma was contributory to Mrs Care’s death, something the family described as “a sad state of affairs”.
During the course of the inquest it was drawn to my attention that owing to the fact Mrs Care had become immobile she was being moved with a hoist. It was speculated that this may be the cause of the bruising that was seen. I had no evidence, however, from anyone who had been involved in moving Mrs Care by this means.
” Open source report
4 Oct 2013 Jean James · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 2 Failure to keep records of doctor review timeframes for GP-referred hospital admissions View source Lack of a time threshold for doctor review and assessment of GP-referred hospital admissions 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
Jean James · 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
Jean James was an 85-year-old woman who developed stomach pain on 5 November 2012, was admitted to hospital with suspected appendicitis at approximately 11:00 on 6 November, and was not seen by a doctor until 17:00. She was later diagnosed with a perforated appendix, underwent surgery, and died in hospital on 19 November 2012. The principal concern was that patients admitted via their GP had no defined timeframe for medical review, unlike patients admitted through the Emergency Department, and that records of review times were not kept.
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 Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to keep records of doctor review timeframes for GP-referred hospital admissions
Wider context from the report “By contrast, where the patient is admitted to the Medical Admissions Unit or the Surgical Receiving Unit after referral by their GP there is no time threshold within which a doctor should review them. Furthermore, I was told that records in this regard are not kept.
On this occasion the question was asked whether, had Mrs James been seen earlier, the outcome may have been different. ████████ felt this was unlikely but he could not exclude the possibility that more prompt treatment by antibiotics may have led to a different outcome.
I do not understand the rationale why patients admitted to hospital via their GP should not be seen within the same timeframe as patients admitted via the Emergency Department. I anticipate one justification for this may be that the GP has already conducted some form of medical examination. While that was the case in this instance I can easily see that there may be circumstances where it would not happen. In that situation it cannot be acceptable for a patient to wait more than four hours before being seen and assessed.
It is equally the case that patients seen by their GP could actually be more unwell than those who present themselves at the Emergency Department.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Cornwall Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a time threshold for doctor review and assessment of GP-referred hospital admissions
Wider context from the report “By contrast, where the patient is admitted to the Medical Admissions Unit or the Surgical Receiving Unit after referral by their GP there is no time threshold within which a doctor should review them . Furthermore, I was told that records in this regard are not kept.
On this occasion the question was asked whether, had Mrs James been seen earlier, the outcome may have been different. ████████ felt this was unlikely but he could not exclude the possibility that more prompt treatment by antibiotics may have led to a different outcome.
I do not understand the rationale why patients admitted to hospital via their GP should not be seen within the same timeframe as patients admitted via the Emergency Department . I anticipate one justification for this may be that the GP has already conducted some form of medical examination. While that was the case in this instance I can easily see that there may be circumstances where it would not happen. In that situation it cannot be acceptable for a patient to wait more than four hours before being seen and assessed .
It is equally the case that patients seen by their GP could actually be more unwell than those who present themselves at the Emergency Department.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations