Concerns raised 4 Failure to maintain emergency department capacity and timely patient flow View source Insufficient social care provision for onward discharge support View source Failure to complete ambulance handovers within the 15-minute target View source Failure to prevent emergency department crowding from patients left awaiting handover 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
Geoffrey Gordon Fuller · 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
Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain emergency department capacity and timely patient flow
Wider context from the report “1. On the day of Mr Fuller’s ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients . ED accommodated the surplus patients on trolleys in corridors, seated within the waiting room or remaining inside ambulances in the parking area outside ED.
2. The situation had not improved as at the date of this Inquest.
3. EDs have a national target for 95% of patients to be admitted, transferred or discharged within 4 hours. It was noted that there is a recent major study which shows that the standardised mortality rate starts to rise from 5 hours after the patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is one extra death for every 82 patients delayed. This increased mortality is partly attributed to the fact that patients in ED are not receiving the surgery or specialist care that is available on the wards.
4. Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients. For the opening months of 2026 approximately 50% of patients have still been in ED after 4 hours .
5. RCHT witnesses reported that over the last few weeks the ED has been regularly required to accommodate over 100 patients (in a unit with a capacity for 42 patients) . This has involved significant numbers of patients still in ED after 12 hours, some still in ED after 24 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 Cornwall Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient social care provision for onward discharge support
Wider context from the report “1. The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR) , these being patients who are medically optimised but cannot be discharged due to lack of onward care support .
2. On the day of the ambulance delay, 7 July 2025, almost 20% of patients in RCHT were recorded as NCTR.
3. The court noted the main cause for the numbers of NCTR patients was insufficient social care provision , whether commissioned by social services or NHS.
4. Investigations in 2022 and 2023 by SWAST and the Healthcare Safety Investigation Branch (HSIB) found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found…
“…..there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.”
5. This court has previously noted data indicating significant vacancies in social care posts in Cornwall are vacant reflecting the national picture of nationwide vacant direct social care posts. [see previous PFD reports on this subject]
6. The court noted that the NHS does not carry responsibility for the recruitment and retention of social care staff or any broad obligation to promote the social care market.
7. The HSSIB report referred to the fact that the organisations immediately required to deal with ambulance delays are ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not have control over the services primarily responsible for ambulance delays, namely social care provision and support. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
8. The court noted the HSSIB report which states that delayed discharges (and consequent ambulance delays) are a national issue which is attributed to a whole system failure of health and social care. The court noted the HSSIB investigation’s first safety recommendation is an urgent ‘whole system’ response to reduce patient harm.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete ambulance handovers within the 15-minute target
Wider context from the report “1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.
2. The total ambulance delay on 7 July 2025 for Mr Fuller was approximately 13 hours, involving delays in both response and handover.
3. The delay in ambulance response was 10 hours and 12 minutes, during which time Mr Fuller was in pain and unable to move due to a dislocated hip.
4. On arrival at Royal Cornwall Hospital (RCHT), Mr Fuller spent a further 2 hours and 52 minutes before being handed over to the emergency department.
5. On 7 July 2025, at RCHT, the average handover time was two hours, 24 minutes with over 211 hours of ambulance availability lost to these handover delays. This is the equivalent of approximately 19 double crewed ambulance (DCA) shifts lost to delays (based on a standard 11-hour shift).
6. Data for the two months before Mr Fuller’s death reveals average handover delays at RCHT of 1 hour and 26 minutes for May 2025, and 1 hour and 27 minutes for June 2025 (beyond the 15 minute target) .
7. Recent data indicates the picture has not improved. Significant average handover delays at RCHT were recorded for every month of 2026 to date (beyond the target 15 minutes) . The data for May 2026 indicates an average handover delay of 1 hour and 22 minutes beyond the 15-minute target.
8. The day before this Inquest, 7 June 2026, SWAST recorded average handover delays at RCHT of 1 hour and 10 minutes .
9. These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case. Such long delays increase the risk of mortality.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent emergency department crowding from patients left awaiting handover
Wider context from the report “10. The court heard evidence of a new policy being implemented by SWAST to try and reduce ambulance resources being tied down in lengthy waits at hospital. After a 90-minute handover delay the ambulance paramedics will provide notice to ED that a patient is being left on a trolley in a corridor with fluids and medications if required so long as that patient is stable. This has led to significant crowding in RCHT emergency department (ED) .
” Open source report
Concerns raised 1 Insufficient capacity for timely admission and treatment of stroke patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Geoffrey Gudgeon · 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
Geoffrey Gudgeon suffered a spontaneous ischaemic stroke on 11 June 2024 and was admitted to West Cornwall Hospital the following morning. After difficulties securing appropriate stroke and rehabilitation beds, he was transferred between care settings before moving to Poldhu Nursing Home, where he died on 1 December 2024. The principal concern was a capacity issue in Cornwall affecting the timely admission and treatment of stroke patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Cornwall Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for timely admission and treatment of stroke patients
Wider context from the report “1) The inquest heard evidence from ████████ stroke consultant, that, at the time of these events, only 35% of patients were admitted to a stroke unit from an ED within 4.5 hours , while only 55% of patients were spending over 90% of their time on a stroke unit . Further, that there were approximately 80 admissions of stroke patients/month or about 900/year. The obvious concern was that there was a capacity issue in Cornwall concerning the timely admission and treatment of stroke patients .
” 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 Use a Stroke Bed Escalation Plan to triage stroke beds more robustly.
Verbatim wording from the response “The Trust has undertaken significant work on improving stroke care at RCHT through our Stroke Improvement Board which meets monthly. A combination of more robustly triaging stroke beds (Stroke Bed Escalation Plan), earlier specialist reviews (increased Stroke Consultant availability in ED and Phoenix Ward), and rapid reviews of in-house data has led to a significant improvement in getting stroke patients to Phoenix Ward within 4 hours and staying there for >90% of their inpatient stay (both nationally mandated targets). In financial year 2024/2025, only 38% of” Source location Response from Royal Cornwall Hospitals NHS Trust
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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 increased Stroke Consultant availability in the Emergency Department and Phoenix Ward for earlier specialist reviews.
Verbatim wording from the response “The Trust has undertaken significant work on improving stroke care at RCHT through our Stroke Improvement Board which meets monthly. A combination of more robustly triaging stroke beds (Stroke Bed Escalation Plan), earlier specialist reviews (increased Stroke Consultant availability in ED and Phoenix Ward), and rapid reviews of in-house data has led to a significant improvement in getting stroke patients to Phoenix Ward within 4 hours and staying there for >90% of their inpatient stay (both nationally mandated targets). In financial year 2024/2025, only 38% of” Source location Response from Royal Cornwall Hospitals NHS Trust
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 Conduct rapid reviews of in-house stroke data to monitor and improve pathway performance.
Verbatim wording from the response “The Trust has undertaken significant work on improving stroke care at RCHT through our Stroke Improvement Board which meets monthly. A combination of more robustly triaging stroke beds (Stroke Bed Escalation Plan), earlier specialist reviews (increased Stroke Consultant availability in ED and Phoenix Ward), and rapid reviews of in-house data has led to a significant improvement in getting stroke patients to Phoenix Ward within 4 hours and staying there for >90% of their inpatient stay (both nationally mandated targets). In financial year 2024/2025, only 38% of” Source location Response from Royal Cornwall Hospitals NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB is responsible for reviewing stroke capacity, demand, bed provision and therapy staffing, rather than the Trust.
Verbatim wording from the response “Patient flow is also linked to staffing, particularly within the therapy teams, which are not currently staffed to national guidelines. The ICB has also undertaken to review this provision.” Source location Response from Royal Cornwall Hospitals NHS Trust
Open published response
Concerns raised 2 Failure to trigger sepsis six and provide required antibiotics when indicated View source Absence of a digital alert for the need to implement sepsis six View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Ramon JERVIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Ramon Jervis died at Royal Cornwall Hospital Truro on 16 July 2023 from neutropenic sepsis, a recognised complication of chemotherapy for testicular cancer. The report found a 20-hour delay in administering antibiotics after observations indicated they were required, and identified the absence of a digital alert that could have alerted staff to implement the Sepsis Six bundle.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger sepsis six and provide required antibiotics when indicated
Wider context from the report “(1) Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should be triggered and that antibiotics were required but this did not happen .
(2) There was an absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a digital alert for the need to implement sepsis six
Wider context from the report “(1) Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should be triggered and that antibiotics were required but this did not happen.
(2) There was an absence of a digital alert on hospital software , which could have alerted staff to the need to implement sepsis six .
” 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 Apply the sepsis screening tool to all blood pressure machines.
Verbatim wording from the response “To continue to raise awareness and increase visibility, the Trust’s sepsis lead is applying the sepsis screening tool to all blood pressure machines.” Source location Response from Royal Cornwall Hospital Trust
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 Maintain mandatory sepsis training for nurses and healthcare assistants as statutory and essential training.
Verbatim wording from the response “Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have been arranged for our doctors with regards to sepsis and this has been implemented.” Source location Response from Royal Cornwall Hospital Trust
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 patient’s story with AMU staff, focusing on neutropenic sepsis, hypothermia and the sepsis six bundle.
Verbatim wording from the response “b. The patient’s story will be shared with AMU staff (following consent), emphasising patient impact, to enhance staff awareness and understanding. The aim is to have this completed within the next six months and this will specifically focus upon neutropenic sepsis, hypothermia and the sepsis six bundle.” Source location Response from Royal Cornwall Hospital Trust
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 Convene an AMU educational awayday focused on sepsis and the deteriorating patient.
Verbatim wording from the response “c. An educational awayday is being arranged for AMU staff, with a focus on sepsis and the deteriorating patient. This will be convened within the next six months.” Source location Response from Royal Cornwall Hospital Trust
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 Increase compliance with sepsis training to 80% within four months and 90% within six months, excluding staff on leave.
Verbatim wording from the response “The Trust has undertaken the following action since the death of Mr Jervis; In the Acute Medical Unit (AMU) the matron has formulated an action plan to promote learning within the ward and wider care-group. This plan includes improving and monitoring compliance with mandatory sepsis training.” Source location Response from Royal Cornwall Hospital Trust
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 Provide sepsis update lunchtime training sessions for doctors.
Verbatim wording from the response “Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have been arranged for our doctors with regards to sepsis and this has been implemented.” Source location Response from Royal Cornwall Hospital Trust
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 Develop a sepsis alert within the new e-Care system to digitally flag when the sepsis six should be actioned.
Verbatim wording from the response “Unfortunately, NerveCentre (a national system) does not allow for this. However, RCHT is implementing a new e-Care digital electronic patient record (EPR) system and the sepsis lead nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the ‘sepsis six’ needs to be actioned.” Source location Response from Royal Cornwall Hospital Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current NerveCentre system cannot support a digital sepsis alert, although an alert is planned for the replacement EPR system.
Verbatim wording from the response “There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six:” Source location Response from Royal Cornwall Hospital Trust
Open published response
Concerns raised 2 Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site View source Failure to give sufficient weight to continuity of clinical care in transfer decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Norma Ann Patricia Tellam · 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
Norma Ann Patricia Tellam suffered a fall causing a proximal femoral fracture and underwent surgery, followed by rehabilitation and further surgery after problems developed with the metalwork. She later suffered an upper gastrointestinal bleed and died on 16 April 2023. Concerns included transfers between hospitals that did not give sufficient weight to continuity of clinical care and did not return her to the hospital responsible for her orthopaedic follow-up.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site
Wider context from the report “1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her .
2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery .
3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Cornwall Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to continuity of clinical care in transfer decisions
Wider context from the report “1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her.
2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery.
3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The assessing ambulance crew has paramount responsibility for the clinical decision about a patient's conveyance destination.
Verbatim wording from the response “On occasion, if it is considered by community hospital staff that a particular hospital would be a more appropriate transfer destination to ensure continuity of care, this can be shared when the 999 call is made. However, clinical decision-making by the assessing ambulance crew is paramount when considering where to convey a patient.” Source location Response from Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust and University Hospitals Plymouth NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further liaison with the Royal Cornwall Hospitals orthopaedic team was not clinically needed until around the later transfer period.
Verbatim wording from the response “On receipt of the referral, the RCHT orthopaedic team discussed a potential admission with their trauma coordinators, and the patient record in UHP documented there was a discussion at 15:00 via telephone. The discussion with the orthopaedic team concluded that community-based hospital care was appropriate, and the transfer to such a hospital should be facilitated by the Cornwall Onward Care Team. Unfortunately, there appeared to be some confusion in the subsequent days where, in the medical records at UHP, the plan was variably referred to as ‘transfer to RCHT’ and ‘transfer to community hospital’. There was no clinical need for further liaison with RCHT regarding Mrs Tellam until around the time of her transfer in March 2023.” Source location Response from Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust and University Hospitals Plymouth NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfers between Liskeard Community Hospital and Derriford Hospital were appropriate and reasonable based on the patient's clinical presentation.
Verbatim wording from the response “When considering the clinical information from the period of care being reviewed, the transfers between Liskeard Community Hospital and UHP were appropriate based on Mrs Tellam’s clinical presentation. Whilst Liskeard Community Hospital was further away from Mrs Tellam’s home, this was unfortunately the only available setting for Mrs Tellam at the time when a community hospital was considered appropriate for her clinical needs.” Source location Response from Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust and University Hospitals Plymouth NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer to Derriford Hospital was correct because urgent assessment was required and it provided the closest prompt access to acute care.
Verbatim wording from the response “Liskeard Community Hospital ‘faces’ the University Hospitals Plymouth NHS Trust (UHP). This means that when a patient in south east Cornwall requires urgent transfer to an emergency acute setting, the hospital commissioned to provide care and treatment to patients, is Derriford Hospital. This hospital is the closest in mileage in comparison to the emergency facility at Royal Cornwall Hospital in Truro (RCHT).” Source location Response from Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust and University Hospitals Plymouth NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Community-based care and transfer to Liskeard were appropriate because there was no urgent need for orthopaedic revision surgery.
Verbatim wording from the response “Mrs Tellam’s care was discussed by CFT and UHP, and it was noted that, during the acute admission, she did not have an urgent need for orthopaedic revision surgery. She had been unwell due to a chest infection and then unfortunately caught covid during her admission. The UHP management plan was for her to have a period of recuperation after her chest infection and prior to consideration of any revision/further surgery on her hip. During that time the aim was for Mrs Tellam to be” Source location Response from Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust and University Hospitals Plymouth NHS Trust
Open published response
Concerns raised 5 Failure to clearly record treatment plans between transferring and receiving clinical staff View source Lack of clear, detailed and direct doctor-to-doctor handovers between hospitals View source Failure to properly record handovers in medical notes View source Failure to agree treatment plans between transferring and receiving clinical staff View source Errors in writing prescriptions for intravenous fluids View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Byron Holmes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Byron Holmes sustained fractured ribs and a fractured sternum in a road traffic collision on 4 April 2022, followed by hospitalisation, delirium, dehydration and declining health. He died at home on 29 May 2022 after returning for palliative care. Concerns included inadequate doctor-to-doctor handover and recording of the treatment plan during a hospital transfer, and a prescription error that delayed intravenous fluids.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record treatment plans between transferring and receiving clinical staff
Wider context from the report “(2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear, detailed and direct doctor-to-doctor handovers between hospitals
Wider context from the report “(1) There was no clear, detailed and direct handover between doctors of the two hospitals
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record handovers in medical notes
Wider context from the report “(3) Any handover which did take place was not properly recorded in Paul's medical notes
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to agree treatment plans between transferring and receiving clinical staff
Wider context from the report “(2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Errors in writing prescriptions for intravenous fluids
Wider context from the report “(4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed.
” 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 Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
Verbatim wording from the response “Both Trusts propose to review the inter-hospital transfer form used by both the discharging and receiving wards to ensure an escalation plan is documented and to ensure that the handover record in both Trusts is consistent. Any revisions to the handover documentation would need to include a prompt for the discharging and receiving nurse to share any relevant details from the medical management plan.” Source location Royal Cornwall Hospitals NHS Trust
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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 Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
Verbatim wording from the response “Both Trusts commit to establishing a task and finish group to review the design of the inter-hospital transfer forms and take forward any developments. This group will be established by the start of October 2024.” Source location Royal Cornwall Hospitals NHS Trust
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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 Deliver human-factors and medication-error training through the revised LEAD programme for leaders, supervisors, and managers, with completion monitored electronically.
Verbatim wording from the response “Whilst training regarding human factors and medication has previously been delivered on an ad hoc basis to all professional groups in the Trust, it is also now part of the revised LEAD programme aimed at all leaders, supervisors, and managers in RCHT. Specific reference to medication errors is made to ensure learning in personal awareness but also that the conditions we create for ourselves (and others) can contribute to slip and lapse errors which can be seen in tasks such as transcription and completing care related tasks.” Source location Royal Cornwall Hospitals NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing Treatment Escalation Plan adequately specified escalation to acute hospital if deterioration occurred, despite omission from the handover form.
Verbatim wording from the response “The patient handover form was completed by the receiving nurse at CFT, however, this did not detail the need to continue to treat the patient for dehydration and what to do in the event of a deterioration. Although specific actions in the event of a deterioration were not documented on the handover form, there was a Treatment Escalation Plan (TEP) dated 4th of April 2022 recorded in Mr Holmes’ paper notes, which did detail that Mr Holmes was for escalation back to the acute hospital in the event he deteriorated. The TEP was followed.” Source location Royal Cornwall Hospitals NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Returning prescriptions to the original prescriber cannot safeguard against prescription errors outside normal hours because medical cover is limited.
Verbatim wording from the response “CFT recognise that an additional option in such circumstances would be for the receiving ward to return to the original prescriber to rectify any prescription issues. Upon review with ward managers, this course of action is routinely taken when prescription errors are detected in normal operating hours, however this is not a safeguard which would apply in the out-of-hours scenario which impacted Mr Holmes.” Source location Royal Cornwall Hospitals NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nurse-to-nurse handover, admission refusal safeguards and occasional doctor handovers are considered sufficient for community hospital admissions.
Verbatim wording from the response “There is no documentation of a handover from the discharging Consultant to the accepting team at Liskeard, however this is in-line with expected practice.” Source location Royal Cornwall Hospitals NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited medical cover makes it infeasible to require doctor-to-doctor handovers for all admissions to nurse-led community hospital wards.
Verbatim wording from the response “There are some additional safeguards in place for more complex presentations. In the scenario where a patient has needs which cannot safely be met by the nurse-led community hospital, an admission can be refused. There have also been cases, where the patient’s needs are complex, where a doctor-to-doctor handover does take place.” Source location Royal Cornwall Hospitals NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A shared handover visible in both Trusts’ electronic systems is impracticable because their electronic patient records have limited interoperability.
Verbatim wording from the response “Within CFT, the verbal nurse-to-nurse handover is documented on a paper record, which is then added to the patient’s paper notes on arrival at the ward. Due to limited communication between the electronic patient records of both Trusts, it is not practicable to produce a shared handover which is apparent on both systems.” Source location Royal Cornwall Hospitals NHS Trust
Open published response
Concerns raised 3 Failure to enter an alert in the digital system when clinical notes have been handwritten View source Lack of an EPMA alert requiring review of ongoing suspension of prescribed medication View source Inconsistencies in record keeping between specialities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Audrey 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
Audrey King was admitted for femoral hernia obstruction and underwent repair on 6 November 2022. Her apixaban was suspended for surgery and not restarted; she suffered a severe stroke on 11 November and died four days later. The principal concerns were inconsistent record keeping between specialties, inadequate alerting when important handwritten notes were made, and no EPMA alert requiring review of the ongoing medication suspension.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enter an alert in the digital system when clinical notes have been handwritten
Wider context from the report “(2) The process for entering an alert in the digital system that clinical notes have been handwritten in the written notes .
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an EPMA alert requiring review of ongoing suspension of prescribed medication
Wider context from the report “(3) The absence of an alert on the EPMA requiring review of the ongoing suspension of prescribed medication .
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistencies in record keeping between specialities
Wider context from the report “(1) Inconsistencies in record keeping between specialities .
” 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 Progress the contracted integrated electronic patient record programme toward operational use from Spring 2025.
Verbatim wording from the response “The Trust is moving towards having all clinical records available electronically and Oracle Health have been awarded the contract for our Electronic Patient Record (EPR) programme. The new EPR will integrate many of our digital and paper-based systems into a single platform, providing a more joined up way of working across our hospitals, improving safety and transforming the way we care. This system is expected to be operational from Spring 2025.” Source location Response from Royal Cornwall Hospitals NHS Trust
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 Require inpatient clinical entries to be recorded in written paper notes, except in specified intensive-care areas, with the change communicated and effective from 13 September 2023.
Verbatim wording from the response “Until this is underway, the Trust has taken the decision to advise all specialties to only record inpatient clinical entries in the written paper notes with the exception of EPMA (which is our electronic prescribing system). The only ward exceptions to this are ITU /EPOC (Intensive care and Enhanced peri-operative care unit) which have an electronic record and high staff to patient ratio, there is no duplication and a paper copy is transferred with the patient when they leave ITU/EPOC. This will ensure all specialities undertaking ward rounds will have one set of written notes to review, along with the drugs chart (ePMA) The decision to revert to recording in the written notes was communication to staff and took effect from 08:00 hours on 13 September 2023.” Source location Response from Royal Cornwall Hospitals NHS Trust
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 prescribing system cannot create suspension alerts, and separate alerts are considered potentially counterproductive because of prescriber alert fatigue.
Verbatim wording from the response “The Trust currently uses Careflow Medicines Management systems to support electronic prescribing across most clinical areas. This system does not have the capability to set up an alert if medications are suspended. However, even if this was an option, it would not be” Source location Response from Royal Cornwall Hospitals NHS Trust
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 Because specialties must record inpatient entries in paper notes, no electronic alert is considered necessary for handwritten clinical entries.
Verbatim wording from the response “Until this is underway, the Trust has taken the decision to advise all specialties to only record inpatient clinical entries in the written paper notes with the exception of EPMA (which is our electronic prescribing system). The only ward exceptions to this are ITU /EPOC (Intensive care and Enhanced peri-operative care unit) which have an electronic record and high staff to patient ratio, there is no duplication and a paper copy is transferred with the patient when they leave ITU/EPOC. This will ensure all specialities undertaking ward rounds will have one set of written notes to review, along with the drugs chart (ePMA) The decision to revert to recording in the written notes was communication to staff and took effect from 08:00 hours on 13 September 2023.” Source location Response from Royal Cornwall Hospitals NHS Trust
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 Existing visual prompts on suspended medicines and ward-round drug-chart reviews are considered sufficient to support medication review without a separate alert.
Verbatim wording from the response “When a drug is suspended it remains on the inpatient chart, with an overlay showing that the drug is suspended (see chart below). When opening the drug chart, the ePMA system gives a clear visual prompt during ward rounds that a current medicine is suspended and this can be re-started if appropriate. Suspended drugs should be reviewed as part of the ward round drug chart review process.” Source location Response from Royal Cornwall Hospitals NHS Trust
Open published response
Concerns raised 4 Failure to communicate medication dosage errors to patients and GPs View source Failure to administer the prescribed steroid dosage accurately View source Failure of prednisolone guidance to reflect bowel perforation risk in diverticular disease View source Failure to apply policies regarding medication dosage errors View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JOHN ALFRED ROBERTS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Alfred Roberts, aged 78, was admitted with vomiting and retching and was found to have an inoperable perforated sigmoid colon. He was discharged home for palliative care and died there on 26 June 2021. The substantive concerns related to an inadvertent reduction in his prednisolone dosage at Royal Cornwall Hospital and the adequacy of medication-error arrangements, as well as omissions in NICE’s BNF guidance about the risk of bowel perforation associated with corticosteroids in people with diverticular disease.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate medication dosage errors to patients and GPs
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer the prescribed steroid dosage accurately
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prednisolone guidance to reflect bowel perforation risk in diverticular disease
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease , albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk , albeit it does make reference to peptic ulceration.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply policies regarding medication dosage errors
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing medicines reconciliation policies were applied and detected the dosage error before harm occurred.
Verbatim wording from the response “The Trust’s policies concerning medicines reconciliation on admission and discharge were applied and did pick up the dosage error before any harm came to the patient. The picture was confused as Mr Robert’s summary care record and GP list recorded his dose as ████████ on alternate days. This was a causative factor in the discrepancy not being picked up on the admission reconciliation. The error was picked up at the discharge reconciliation and recorded on the ePMA system in an ‘intervention note’ but hindsight should also have been recorded on the Trust’s incident management system-Datix.” Source location Response from Royal Cronwall Hospitals NHS Trust
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 Existing procedures did not require reporting a no-harm dosage discrepancy to the GP when no post-discharge GP action was needed.
Verbatim wording from the response “As stated in evidence during the inquest hearing over 12 - 14 April 2023, the dosage discrepancy caused no harm to Mr Roberts and there was no action required by the GP in relation to the dose discrepancy of ████████ doses administered from the 7th-13th June. It is not within our procedures to communicate to the GP incidents that cause no harm to the patient and require no action by the GP following discharge.” Source location Response from Royal Cronwall Hospitals NHS Trust
Open published response
Concerns raised 9 Failure of hospital clinicians and paramedics to coordinate transfer information View source Failure of nursing handovers to convey complete and accurate clinical information View source Failure to identify required ambulance type when requesting transfer View source Uncertainty about compatibility of transfer equipment with available ambulances View source Failure to direct withholding of anticoagulation during assessment of possible neurological injury View source Failure to escalate care after deteriorating neurological observations View source Failure of transfer staff to manage intubated and ventilated patients safely View source Unavailability of airway support during time-critical patient transfer for CT View source Failure to appropriately deploy agency nurses in demanding Medical Admissions Unit positions View source See 6 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
Karen Lesley Peters · 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
Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital clinicians and paramedics to coordinate transfer information
Wider context from the report “3. Transfer of time critical patients
I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team:
(a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required;
(b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way.
I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard.
I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue?
I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance?
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing handovers to convey complete and accurate clinical information
Wider context from the report “3. The quality of handover information
I heard from two nurses, Nurse A and Nurse P. There was a clear conflict in their respective evidence as to what information was conveyed between them at handover. In particular, there was conflict as to whether Nurse A was advised of Karen’s earlier fall and the need for hourly neurological observations.
████████ explained at Inquest that he had now directed that all nursing handovers must be undertaken by reference to the Nursing Record. One of my concerns arising out of this was that there was no entry in the Nursing record advising of the need for the patient to undergo a CT Scan if there was a drop in recorded levels of consciousness. That note was only to be found in the medical records and neither Nurse A nor Nurse P considered these. ████████ explained to me that there will be an ongoing audit in relation to the quality and accuracy of nursing handovers. I would be pleased to learn from you the outcome of that audit.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify required ambulance type when requesting transfer
Wider context from the report “3. Transfer of time critical patients
I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team:
(a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required;
(b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way.
I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard.
I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue?
I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance?
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about compatibility of transfer equipment with available ambulances
Wider context from the report “3. Transfer of time critical patients
I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team:
(a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required;
(b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way.
I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard.
I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue?
I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance?
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to direct withholding of anticoagulation during assessment of possible neurological injury
Wider context from the report “1. Following Karen’s fall at 14:00 hours, the medical staff should have directed that Karen was not to receive any further anticoagulation medication until staff were satisfied that her neurological status was stable. The entry in the notes failed to do this.
At Inquest, ████████, a Consultant Neuro-Surgeon from Derriford, indicated that the administration of anticoagulation treatment to a patient under observation for a possible neurological injury was absolutely contra-indicated.
Would you please let me know how you propose to ensure a similar oversight will not happen again in the future.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care after deteriorating neurological observations
Wider context from the report “4. Measuring and Recording GCS
After her fall at 14:00 hours an entry was made in the medical record that Karen was to have a CT scan in the event that her levels of consciousness fell. At 20:00 hours Nurse P noted a 1 point reduction to 14. At midnight a further set of observations (performed by an unidentified nurse) noted a further reduction to 13. On neither occasion was Karen sent for a CT scan nor was her treatment otherwise escalated.
████████ accepted at Inquest the need for continued education and training. I would be pleased to hear from you of the outcome in this regard.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of transfer staff to manage intubated and ventilated patients safely
Wider context from the report “3. Transfer of time critical patients
I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team:
(a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required;
(b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way.
I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard.
I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue?
I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance?
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of airway support during time-critical patient transfer for CT
Wider context from the report “2. At 06.15 hours on 29 March, Karen was found to have a GCS of 6. She was sent for an immediate CT Scan and this was completed within 45 minutes, which I found to be commendable.
I heard evidence, however, from a ████████ who was the F1 doctor who took Karen to the CT scanner. He told me that no airway support was available to him at that time. He felt exposed and it was plain that Karen was similarly exposed. Fortunately, there were no complications during the course of the Scan, but it is easy to see that in similar circumstances, a problem could develop that the Junior doctor looking after the patient would be unable to resolve.
I would be grateful if you could let me have your thoughts as to how you propose to address this difficulty.
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately deploy agency nurses in demanding Medical Admissions Unit positions
Wider context from the report “2. Deployment of Agency Staff.
On the night of 28 March 2013, Nurse A from Plan B Nursing Agency had been asked to provide cover. She started her Night Shift working in the back area of A & E. A Sister in that department was then contacted by the Site Co-ordinator and, as a consequence, Nurse A was then moved to cover a Bay in MAU. Subsequently, another nurse within MAU became ill and had to go home. Nurse A was then additionally asked to look after that further Bay. At 23:15 hours Karen was then moved into one of the Bays for which Nurse A was responsible.
My concern is whether it is appropriate to put Agency Nurses in such demanding positions ahead of nurses already employed by RCHT. I would welcome your thoughts on this and whether any changes to practice have or will be implemented as a consequence.
” Open source report
17 Jan 2014 JULIA SHEEREN DELL · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 4 Lack of formal handover when primary care responsibility changed View source Failure to act on a care plan received from the Community Mental Health Team View source Failure of primary care to maintain involvement and awareness of fluctuating mood View source Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing 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
JULIA SHEEREN DELL · 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
Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.
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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal handover when primary care responsibility changed
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on a care plan received from the Community Mental Health Team
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of primary care to maintain involvement and awareness of fluctuating mood
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012” . He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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 Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing
Wider context from the report “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care.
At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death.
(1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012.
(2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing
” 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